Equitable Stroke Care
Sep 13, 2021 Cassie Tomlin
Across the U.S., stroke rates are on the decline. But stroke is still extremely dangerous and deadly, especially for Black Americans, who remain more likely to both have a stroke and die from one compared to their white counterparts. Black patients are more likely to suffer a stroke at a younger age and are more likely to develop a post-stroke disability than patients of other races and ethnicities.
The reasons are complicated, but Cedars-Sinai is identifying and addressing disparities through research by physicians dedicated to achieving better care for people of color.
"Our patients at Cedars-Sinai have great clinical outcomes after acute stroke. And we want to ensure that we're providing excellent care to everyone."
Investigating stroke treatment
Dr. Lindsey Ross, a neurosurgeon, is collaborating with Cedars-Sinai's Office of Health Equity to lead a thorough analysis of the health system's stroke patients and their experiences and outcomes.
Cedars-Sinai's stroke program is one of the best on the West Coast—patients treated here have among the lowest death rates for ischemic stroke in the country. But Dr. Ross and her colleagues are studying whether certain national trends—such as that Black patients wait longer in the emergency department before being treated for stroke than white patients—are mirrored at Cedars-Sinai.
"Our patients at Cedars-Sinai have great clinical outcomes after acute stroke, and we want to ensure that we're providing excellent care to everyone," says Dr. Ross.
The project is one of Cedars-Sinai's contributions to the Institute for Healthcare Improvement's Pursuing Equity Learning and Action Network, a nationwide collaborative collecting data about disparities. Dr. Ross and the group began the work in October 2020 and will continue until March 2022.
Dr. Ross says if the research helps identify an opportunity to improve equity in stroke care, her team will develop strategies to do so—but it won't stop there.
"You have to continually monitor these benchmarks," she says. "It's an ongoing process."
In addition to treating patients to the highest standard inside the hospital, Dr. Ross says, Cedars-Sinai helps abate disparities through community outreach and education.
"As a health system, we can work against mistrust that may impact patients' care," she says. "We offer programs that help educate the community about stroke symptoms and help patients get follow up care when they leave the hospital. These efforts can improve outcomes."
Making a deeper difference
Dr. Jennifer Harris, a Cedars-Sinai neurologist specializing in stroke care, is similarly focused on defining and preventing stroke disparities. She plans to continue research similar to work she recently completed at Columbia Medical Center.
In a study published this year, Dr. Harris examined six years of data about patients treated for stroke at Columbia, including their allostatic load—a measurement of the burden of chronic stress detected in a body through certain hormones and other indicators. She found that Black patients who suffered stroke and had higher allostatic load suffered more cognitive impairment at discharge than white or Latino patients.
Dr. Harris says her findings reinforce the need for more proactive approaches to addressing disparities. She says traditional stroke risk factors—such as hypertension—don't account entirely for the discrepancies in outcomes between Black and white patients. The link between Black patients' allostatic load and poor outcomes points to the importance of keeping people well on all levels.
"Evidence suggests that the source of stroke disparities lies in social determinants of health—conditions in which people are born, live and work—and their influence on risk factors," Dr. Harris says. "The effects of these social determinants show up as chronic, socially structured stress. Maybe interventions that target such stress can improve post-stroke outcomes. It's important to make sure Black people have equal access to healthcare and education, and to make sure neighborhoods are safe so communities and individuals can be healthy."
Dr. Harris practices equity in action by teaching fellows and residents and treating patients in the hospital, the clinic and through the telestroke program. She says Cedars-Sinai's stroke nurses focus on important conversations with all patients to better understand the situations impacting their health.
"You have to really take some time when you're talking to patients about prevention," Dr. Harris says. "If someone hasn't taken their medication, we have to take the time and ask why. When people don't make it to follow-up appointments, we have to understand why—then we can help them."