Veterans Administration Acute Stroke (VASt) Study
Lack of Race/Ethnic-Based Differences in Utilization of Stroke-Related
Procedures or Services
Larry B. Goldstein, MD; David B. Matchar, MD; Jennifer Hoff-Lindquist, MS;
Gregory P. Samsa, PhD; Ronnie D. Horner, PhD
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Background and Purpose—Race/ethnic-based disparities in the utilization of health-related services have been reported.
Data collected as part of the Veterans Administration Acute Stroke Study (VASt) were analyzed to determine whether
similar differences were present in patients admitted to Veterans Administration (VA) hospitals with acute ischemic
stroke.
Methods—VASt prospectively identified stroke patients admitted to 9 geographically separated VA hospitals between
April 1995 and March 1997. Demographic characteristics and all inpatient diagnostic tests/procedures were recorded.
Frequencies were compared with ␹2 tests.
Results—Of 1073 enrolled patients, 775 (white, n⫽520; nonwhite, n⫽255, including 226 blacks and 28 HispanicAmericans) with ischemic stroke were admitted from home. Mean ages (71.0⫾0.6 versus 71.9⫾0.4 years; P⫽0.25) and
Trial of ORG 10172 in Acute Stroke Treatment (TOAST) stroke types (atherothrombotic, 12.9% versus 13.3%;
cardioembolic, 16.5% versus 18.0%; lacunar, 26.4% versus 27.1%; other, 1.4% versus 2.0%; unclassified, 42.9% versus
39.6%; P⫽0.89) for whites versus nonwhites were similar. There were no race/ethnic-based differences in the utilization
of brain CT (91.0% versus 92.2%; P⫽0.58), MRI (36.2% versus 41.6%; P⫽0.14), transthoracic (52.5% versus 53.7%;
P⫽0.75) or transesophageal echocardiography (10.2% versus 10.6%; P⫽0.86), 24-hour ECG (3.3% versus 1.6%;
P⫽0.17), carotid ultrasound (64.0% versus 62.0%; P⫽0.57), carotid endarterectomy (1.5% versus 0.8%; P⫽0.38),
rehabilitation evaluations (71.0% versus 76.5%; P⫽0.11), speech therapy (9.6% versus 12.6%; P⫽0.21), recreational
therapy (3.1% versus 2.0%; P⫽0.37), or occupational therapy (16.0% versus 19.6%; P⫽0.20) for whites versus
nonwhites, respectively. Angiography was performed less frequently (3.1% versus 8.5%; P⫽0.01) and ECG more
frequently (81.6% versus 73.5%; P⫽0.01) in nonwhites. The proportions of patients discharged functionally
independent were also similar (52% of whites and 50% of nonwhites had discharge Rankin Scale scores of 0, 1, or 2;
P⫽0.63).
Conclusions—Aside from cerebral angiography and ECG, there were no race/ethnic-based disparities in the utilization of a
variety of stroke-related procedures and services. The difference in the use of angiography is unlikely to be related to a
difference in screening for carotid endarterectomy because there was no difference in the frequency of carotid ultrasonography. The reason ECG was obtained more frequently in nonwhites is uncertain. (Stroke. 2003;34:999-1004.)
Key Words: health services 䡲 racial differences 䡲 stroke
S
tudies consistently document race/ethnic and socioeconomic
disparities in access to care and in the use of specific treatment
modalities in the United States.1,2 This difference extends to both
cardiovascular3–9 and cerebrovascular10–14 disease. Although there
are a variety of potential causes for this apparent inequality, the
reasons for its existence are not fully explained.15,16
The Veterans Affairs Health Administration (VA) in the
United States is an equal-access healthcare system open to all
qualifying veterans, thereby largely eliminating socioeconomic
See Editorial Comment, page 1003
barriers to care among participants. The Veterans Administration Acute Stroke Study (VASt) prospectively collected data from a cohort of patients hospitalized with
acute ischemic stroke. In the present study VASt data were
analyzed to determine whether there were race/ethnic
differences in patients’ evaluations for ischemic stroke or
its management.
Received August 21, 2002; final revision received October 16, 2002; accepted October 30, 2002.
From the Durham Veterans Affairs Medical Center, Durham, NC (L.B.G., D.B.M., J.H-L.); Departments of Neurology (L.B.G.) and General Internal
Medicine (D.B.M., G.P.S.), Department of Medicine; Stroke Policy Program, Center for Clinical Health Policy Research (L.B.G., D.B.M.); and Center
for Cerebrovascular Disease (L.B.G., D.B.M., G.P.S.), Duke University, Durham, NC; and Office of Minority Health and Research, National Institute
of Neurological Disorders and Stroke, Bethesda, Md (R.D.H.).
Correspondence to Larry B. Goldstein, MD, Duke Center for Cerebrovascular Disease, Stroke Policy Program, Center for Clinical Health Policy
Research, Box 3651, Duke University Medical Center, Durham, NC 27710. E-mail [email protected]
© 2003 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000063364.88309.27
999
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April 2003
Subjects and Methods
TABLE 1.
Demographics and Baseline Characteristics
Study Design
The design of the VASt Study has previously been published.17
Briefly, VASt was a 9-site nationwide prospective cohort study of
1073 patients with acute stroke hospitalized within the VA Health
Administration between April 1, 1995 and March 31, 1997. Because
of confidentiality, the individual sites are not identified. Data on
acute care practices, the subject of the present analysis, were
collected through medical record review with the use of a standardized chart abstraction protocol. The study protocol was approved by
each site’s institutional review board.
Whites
(n⫽520)
Nonwhites
(n⫽255)
P
Mean age⫾SEM
71.0⫾0.6
71.9⫾0.4
0.25
Charlson Index
0.6⫾0.1
0.5⫾0.1
0.47
Prior functional deficit
19.2%
24.3%
0.10
College education
31.8%
22.7%
0.02
Income⬎$10,000
47.5%
24.2%
⬍0.01
8.8⫾0.1
8.4⫾0.2
0.06
Feature
Stroke severity (CNS)
Stroke subtype (TOAST)
Patients
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A research assistant identified patients with possible stroke within 48
hours of hospital admission by screening admission logs. The
diagnosis was then confirmed by review of medical records and
discussion with the patient’s attending physician. This method of
patient identification was supplemented by review of the hospital’s
discharge files for diagnoses of intracerebral hemorrhage (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 431) or acute cerebral infarction (ICD-9-CM
code 434 or 436). Patients whose stroke was iatrogenic, was due to
brain trauma or neoplasm, occurred during hospitalization for other
medical conditions, was an extension of previous stroke, or occurred
⬎7 days before admission were excluded. Patients with a prior
history of stroke in whom the index stroke was not an extension of
a previous stroke were included. Thus, the overall study cohort
consisted of patients with ischemic or hemorrhagic stroke within the
prior week. The present analysis focused on patients with ischemic
stroke admitted from home, thereby eliminating potential confounding due to evaluations that could have been done at another
institution and limitations in evaluations in those previously
institutionalized.
Demographic Variables, Diagnostic Testing, and
Clinical Course
Demographic characteristics included age, sex, and self-reported
race/ethnic group (white, black, Hispanic, other). Comorbid conditions were classified with the Charlson Index.18 Stroke subtype was
assigned according to the Trial of ORG 10172 in Acute Stroke
Treatment (TOAST) criteria with the aid of a computerized system
to optimize reliability.19 Stroke severity was determined retrospectively with the Canadian Neurological Scale.17,20 Use of a variety of
diagnostic studies commonly used in stroke patients’ evaluations
were recorded, including brain CT, MRI, cerebral angiography,
transthoracic and transesophageal echocardiography, 24-hour ECG,
carotid ultrasound, carotid endarterectomy, and rehabilitation,
speech, recreational, and occupational therapy evaluations. The
proportions of patients with do not resuscitate (DNR) orders and with
a chart note indicating clinical worsening during the first 24 hours of
hospitalization, as well as the patients’ functional status at hospital
discharge (Rankin Scale score21), were recorded.
Atherothrombotic
12.9%
13.3%
Cardioembolic
16.5%
18.0%
Lacunar
26.4%
27.1%
1.4%
2.0%
42.9%
39.6%
Other defined
Unclassified
CNS indicates Canadian Neurological Scale; TOAST, Trial of ORG 10172 in
Acute Stroke Treatment.
other baseline characteristics, initial stroke severity, and
TOAST stroke subtype based on race/ethnic group. Higher
proportions of whites were college educated and had annual
incomes ⬎$10 000. There were no significant race/ethnic
differences based on the patients’ mean ages or comorbid
conditions (Charlson Index). The proportions with prior
functional deficits, initial stroke severities (based on Canadian Neurological Scale ratings), and stroke subtypes
(TOAST classification) were similar.
Table 2 compares the use of diagnostic tests and Table 3
the use of various interventions for stroke management. There
were no race/ethnic-based differences in the utilization of
brain CT, MRI, transthoracic or transesophageal echocardiography, 24-hour ECG, carotid ultrasound, carotid endarterectomy, rehabilitation evaluations, or speech, recreational, or
occupational therapy for nonwhite versus white subjects
(P⬎0.05, respectively). Angiography was performed less
frequently (P⫽0.01) and ECG more frequently (P⫽0.01) in
nonwhites.
Because it was available for routine clinical use only
during the last portion of data collection and reflected the
generally nonhyperacute VA stroke population, ⬍1% of the
patients were treated with intravenous tissue plasminogen
TABLE 2.
Utilization of Diagnostic Tests
Statistical Analysis
Because of sample size considerations, whites were compared with
subjects of other race/ethnic groups (nonwhites) for these analyses.
Continuous variables were compared with t tests and frequencies
with ␹2 tests.
Results
Of 1073 enrolled patients, 775 (nonwhite, n⫽255, including
226 blacks and 28 Hispanics; white, n⫽520) with ischemic
stroke were admitted from home. The individual sites enrolled 61 to 118 patients each (median, 32% nonwhites;
range, 14% to 59%). Because this was a veteran population,
only 2% of the patients were women (0.8% of nonwhites and
2.5% of whites; P⫽0.10). Table 1 compares demographics,
0.89
Whites
(n⫽520), %
Nonwhites
(n⫽255), %
P
Brain CT
91.0
92.2
0.58
Brain MRI
36.2
41.6
0.14
TTE
52.5
53.7
0.75
TEE
10.2
10.6
0.86
3.3
1.6
0.17
64.0
62.0
0.57
8.5
3.1
0.01
73.1
81.6
0.01
Test
24-h ECG
Carotid ultrasound
Cerebral angiography
ECG
TTE indicates transthoracic echocardiography; TEE, transesophageal echocardiography.
Goldstein et al
TABLE 3.
Utilization of Interventions
Whites
(n⫽520), %
Intervention
tPA
Antiplatelet drug
Carotid endarterectomy
Nonwhites
(n⫽255), %
P
0.73
0.6
0.4
93.2
92.1
0.59
1.5
0.8
0.38
Rehabilitation evaluation
71.0
76.5
0.11
Physical therapy
70.5
74.9
0.27
Speech therapy
9.6
12.6
0.21
Occupational therapy
16.0
19.6
0.20
Recreational therapy
3.1
2.0
0.37
tPA indicates tissue plasminogen activator.
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activator (tPA) (Table 3). Similar and high proportions of
patients were given platelet antiaggregants. The use of
rehabilitation services was also similar between whites and
nonwhites.
Similar proportions of whites and nonwhites had written
DNR orders in the case of cardiopulmonary arrest (Table 4).
There was no race/ethnic difference in the proportions of
patients with clinical deterioration during the first 24 hours of
hospitalization. The proportions of patients discharged functionally independent were also similar (52% of whites and
50% of nonwhites had discharge Rankin Scale scores of 0, 1,
or 2; P⫽0.63).
Discussion
The main finding of the present analysis is that there were
generally no significant race/ethnic-based differences in
the utilization of a wide variety of diagnostic studies and
treatments in a cohort of patients with acute ischemic
stroke admitted from home to VA Health Administration
hospitals. We focused on this subgroup of stroke patients
TABLE 4.
Clinical Course
Whites
(n⫽520), %
Nonwhites
(n⫽255), %
P
DNR order
11.9
11.4
0.82
Clinical worsening
12.7
14.1
Feature
Discharge Rankin Score
0.20
0.12
0
17.5
13.7
1
30.0
32.6
2
3.5
3.5
3
12.1
10.2
4
24.2
21.6
5
4.6
7.1
Dead
5.6
10.2
DNR indicates do not resuscitate; Clinical worsening, proportion with clinical
deterioration over first 24 hours of hospitalization; Rankin score (0, no
disability; 1, slight disability but able to carry out usual activities; 2, unable to
carry out some activities, but able to look after own affairs without assistance;
3, requiring some help, but able to walk without assistance; 4, unable to walk
without assistance and unable to attend to own bodily needs without
assistance; 5, bedridden, incontinent, and requiring constant nursing care and
attention).
Race/Ethnicity and Stroke Care
1001
to avoid differences in evaluations that could have been
related to studies performed in other hospitals or settings in
transferred patients. Because the vast majority of nonwhite
patients were black (88%), we compared the care of
self-described white versus nonwhite patients as a group.
However, the results were substantially the same when
Hispanics were excluded from the analyses and whites
were compared with blacks (data not shown). Because of
the relatively small number of patients, it was not appropriate to analyze the care of Hispanic patients separately.
Therefore, these data do not address the possibility that
care given to Hispanics might differ from care given to
whites or blacks. However, there is no reason to believe
that this would be the case.
Race/ethnic-based differences in the utilization of certain stroke-related diagnostic tests and procedures have
been found in other studies.3,10 –14 Some of these differences have been at least partially ascribed to race/ethnicbased differences in stroke subtypes. For example, blacks
are one third to one fourth as likely to have carotid
endarterectomy performed compared with whites.10,11,22,23
However, in some studies proportionally more whites have
carotid atherosclerosis and proportionally more blacks
have intracranial small-vessel type disease.24 –29 The higher
frequency of intracranial small-vessel disease in blacks
may be partially attributed to poorer hypertension control
among blacks, which could be related in part to socioeconomic and other barriers to preventive care.1,2,23 In the
present study the proportions of patients with small-vessel
type (ie, TOAST lacunar subtype) stroke were similar
between whites and nonwhites (Table 1). Although nonfinancial barriers to care may exist (eg, distance to a VA
medical facility), because all of the patients included in
this study were cared for within the VA health system,
barriers or lack of barriers to preventive services are
expected to be similar regardless of the patient’s socioeconomic status. This may partially explain the lack of
race/ethnic-based differences in stroke subtypes, a hypothesis that could be tested by directly comparing VA and
non-VA hospitals in future studies.
Of the tests performed, race/ethnic-based differences were
found only for routine ECG and cerebral angiography. ECG
was obtained more frequently in nonwhites than whites
(Table 2). Routine ECG should generally be performed in all
stroke patients,30 and the reason(s) the test was not done in
18% of nonwhites and 26% of whites is not clear. This
apparent deficiency should be addressed through quality
improvement activities.
Cerebral angiography was more commonly performed in
whites than nonwhites, although it was used infrequently
in either group (Table 2). Cerebral angiography may be
used for a variety of reasons, including evaluation for
large-vessel intracranial atherosclerosis,31 diagnosis of
unusual causes of stroke such as vasculitis32 or dissection,33 and, in many cases, before proceeding with carotid
endarterectomy.34 As indicated below, there were no race/
ethnic-based differences in the utilization of carotid ultrasonography, a screening test generally done before angiography.35 Therefore, a disparity in physicians’ intent to
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Stroke
April 2003
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evaluate a patient for endarterectomy on the basis of
race/ethnic group would not be expected to account for the
difference in the use of angiography. However, there may
have been race/ethnic-based differences in the results of
carotid ultrasonography or other clinical features that
affected the decision to proceed with the more invasive
test.
Although important, race/ethnic-based differences in clinical presentation do not fully explain differences in service
utilization reported in other studies. For example, noninvasive carotid imaging is a critical step in the presurgical
evaluation for carotid endarterectomy. Blacks were previously found to less frequently have carotid imaging compared
with whites, even after controlling for clinical presentation
and other factors.13 Part of this difference may be due to
race/ethnic-based differences in aversion to surgery.36 If
patients indicate to their physicians that they would not
consider an operative procedure, it is not surprising that
preoperative diagnostic studies would be deferred. Similar
aversion to invasive procedures, as well as differences in
initial stroke severity,17 may also explain part of the lower
reported use of intravenous tPA among blacks compared with
whites.14 In the present study there were no race/ethnic-based
differences in the utilization of noninvasive carotid imaging
(ie, carotid ultrasound; Table 2), and although the numbers
were quite small, there were no differences in the use of tPA
or carotid endarterectomy (Table 3). Therefore, there is no
evidence that aversion to surgery or invasive procedures was
important in this cohort.
Although a race/ethnic-based difference in initial stroke
severity was previously reported for this entire study cohort,17
the difference between whites and nonwhites in the subgroup
of patients with ischemic stroke was small and not statistically significant. In addition, there were no significant imbalances between whites and nonwhites with respect to comorbidity, the proportion with prior functional deficits, or the
proportion with DNR orders that might confound the finding
of a general lack of race/ethnic-based differences in the
process or outcome of these patients’ care.
In summary, we found no major unexplained race/ethnicbased inequalities in the utilization of stroke-related diagnostic procedures or treatments among patients cared for within
VA Health Administration hospitals. Although the reasons
for differences found in other studies are likely complex and
remain only partially explained, the present results suggest
that unmeasured barriers to care may be contributing to this
discrepancy.
Acknowledgments
This work was supported by a grant from the Department of Veterans
Affairs (Health Services Research and Development Service, SDR
93-003). Dr Goldstein was supported in part by a National Institutes
of Health Midcareer Development Award in Patient-Oriented Research (K24 NS02165). Dr Horner was supported in part by a grant
from the VA Cooperative Studies/Epidemiologic Research and
Information Center Programs (CSP/ERIC 602).
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Editorial Comment
Diagnostic Disparities: Still Exist?
The VA Stroke (VASt) Study presented here by Goldstein
and coworkers attempts to review race/ethnic-based differences in the utilization of stroke-related procedures or services. Inequality in quality health care for minorities have
been addressed in several recent articles such as presented by
Fiscella and co-authors.1 Oddone and colleagues have presented racial variations in the rates of carotic angiography and
endarterectomy in patients with stroke and transient ischemic
attack.2 Disparities in health care fore minorities reached
national attention with the studies of Schulman and associates
in examining the practice patterns of physicians in both
minorities and women in cardiovascular evaluations.3
Johnston and coworkers have presented evidence of the
disparate use of rtPA in blacks.4 Yet, VASt and such studies
continue to note the ongoing disparity in the utilization of
invasive diagnostic procedures to fully evaluate diseases in
minorities.
Goldstein and associates have presented a thorough analysis prospectively of stroke patients admitted to 9 geographically separated VA hospitals. They based their investigation
within the Veterans Health Administration in the United
States as an equal-access health care system mainly eliminating socioeconomic barriers to health care to all who qualify
for such care, in itself a self-selected group that also excludes
women from the study, as they note. Of interest was the lack
of TOAST ischemic stroke type differences for whites versus
nonwhites. Thus the issue is again raised from other studies5–7
suggesting more whites have carotid atherosclerosis and more
blacks have intracranial small-vessel-type disease, the latter
raising the questionable role of hypertension control in
blacks.
Thus the VASt study raises again the question: why the
limited use of a basic definitive diagnostic study in minorities? Is the noninvasive ECG as this study would suggest
substituting for the more diagnostic invasive cerebral angio-
gram because hypertensive cardiovascular and cerebrovascular small-vessel disease is the anticipated cause of stroke in
blacks? The VASt study suggests TOAST ischemic stroke
types are the same in whites and nonwhites. Once again
evidence is presented here of the disparity in sufficient
diagnostic evaluation of diseases in general and via the VASt
study for stroke in particular. As this study indicates, larger
numbers of patients to include more Hispanics and women
must pursue these questions for a clearer understanding of the
pathogenesis and appropriate treatment for specific types of
stroke in minorities.
Finally, one must continue to examine the attitudes and
preconceptions of health care providers in the management of
patients with stroke or at risk for stroke. The VASt study
suggests there was no evidence that aversion to surgery or
invasive procedures was an issue in the cohort studied. Stroke
is an equal-opportunity disease and therefore deserves equal
access to definitive diagnostic studies. Therefore, the contrary
opinion is offered here that the VASt study did indeed find
major unexplained race/ethnic-based inequalities in the utilization of stroke-related diagnostic procedures, the disparate
use of the definitive cerebral angiogram versus the more
inconclusive ECG. Furthermore, the study results suggest in
fact measurable barriers to stroke care that maybe contributing to this discrepancy—the attitudes, preconceived notions,
and limited understanding of the etiology of stroke in
minorities.
Edgar J. Kenton III, MD, Guest Editor
Cerebrovascular Diseases
Mainline/Jefferson Health System
Wynnewood, Pennsylvania
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Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Veterans Administration Acute Stroke (VASt) Study: Lack of Race/Ethnic-Based
Differences in Utilization of Stroke-Related Procedures or Services
Larry B. Goldstein, David B. Matchar, Jennifer Hoff-Lindquist, Gregory P. Samsa and Ronnie
D. Horner
Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Stroke. 2003;34:999-1004; originally published online March 20, 2003;
doi: 10.1161/01.STR.0000063364.88309.27
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