Ethnic Inequalities Persist in Stroke Care, Outcomes

Major and persistent inequalities in stroke outcomes and care remain in the United Kingdom, as patients in London report differences in both areas, according to a study published in JAMA Network Open.¹ Factors related to stroke and sociodemographic data could not fully explain the disparities.

Stroke incidence and mortality related to stroke have been higher in racial and ethnic minority populations,² but functional outcomes have not been as readily studied. Patients who are not admitted to the hospital for their stroke are often excluded from these studies, which could overestimate the quality of care received. Using data from the UK could help in eliminating the financial barrier to hospital admittance for those who may not otherwise afford it. This study aimed to assess the differences in outcomes by ethnicity through 5 years of follow-up.

Inequalities persist in stroke outcomes and care. | Image credit: © peterschreiber.media - stock.adobe.com

This cohort study comprised part of the South London Stroke Register (SLSR). All participants in the SLSR were those who had an incident stroke since 1995. All participants lived in London, and their ethnicities was self-reported. Participants were split into 4 groups: Black African, Black Caribbean, White, and Other. Thrombolysis and stroke unit admission were acute care interventions. All functional outcomes were measured after 3 months and 5 years through either a telephone or face-to-face interview or through a questionnaire. Occupation, education, and Index of Multiple Deprivation were used for estimating socioeconomic status.

There were 7280 participants registered between 1995 and 2021 who had a mean (SD) age of 69.3 (15.2) years. White ethnicity was reported in 65.1% of participants, Black Caribbean ethnicity in 15.0%, Black African ethnicity in 11.8%, and Other ethnicity in 8.13%. The age of the first stroke was significantly lower in Black African participants compared with White participants (59 [14] years vs 72 [14] years).

Lower thrombosis rates and arriving at the hospital more than 4 hours after stroke onset were both more likely in Black Caribbean participants compared with Black African and White participants (60.0% vs 53.8% vs 51.2%), which persisted through all cohorts. Black African and Caribbean participants were more likely to be admitted and receive stroke unit care. This association was reducted when adjusting for the year of the stroke but was not altered after futher adjusting (Black African participants: adjusted OR [aOR], 1.27; 95% CI, 1.03-1.57; Black Caribbean participants: aOR, 1.31; 95% CI, 1.11-1.56).

The lowest survival rates were seen in White participants across all cohorts and the highest were seen in Black African participants; White participants had the largest improvements over time. The relative survival advantage was reduced when adjusting for stroke year and age in both Black African (HR, 0.65; 95% CI, 0.55-0.76) and Black Caribbean (HR, 0.84; 95% CI, 0.76-0.93) participants.

A total of 44.1% of the participants were alive after 5 years. Disability was higher in Black Caribbean and White participants after 3 months compared with Black African participants. No significant improvements were found in functional outcomes. Poststroke disability and inactivity were associated with Black African, Black Caribbean, and other ethnicities.

There were some limitations to this study. The early cohort did not have some variables available, such as education, and could not be used for analysis. Also, follow-up was challenging due to the long period of time, and Black African participants were more likely to have missing data. Participants who were in the Other ethnicity also were not further analyzed due to a low number of participants.

Ethnic inequalities were prevalent in this cohort living in London. Thrombolysis was low in Black Caribbean participants. The authors concluded that “poorer poststroke functional outcomes might be partly explained by differential comorbidity profiles, but nonmedical social determinants of health might also play a role.”

References

1. Emmett ES, O’Connell MDL, Pei R, et al. Trends in ethnic disparities in stroke care and long-term outcomes. JAMA Netw Open. 2025;8(1):e2453252. doi:10.1001/jamanetworkopen.2024.53252

2. Howard VJ, Kleindorfer DO, Judd SE, et al. Disparities in stroke incidence contributing to disparities in stroke mortality. Ann Neurol. 2011;69(4):619-627. doi:10.1002/ana.22385