Letter by Willey and Williams Regarding Article, "Racial and Ethnic Disparities in the Utilization of Thrombectomy for Acute Stroke: Analysis of Data From 2016 to 2018".
Letter by Willey and Williams Regarding Article, "Racial and Ethnic Disparities in the Utilization of Thrombectomy for Acute Stroke: Analysis of Data From 2016 to 2018".
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Willey 和 Williams 关于文章“使用血栓切除术治疗急性中风的种族和民族差异：2016 年至 2018 年数据分析”的信函。
DOI：
10.1161/strokeaha.119.027577
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发表时间：
2019
期刊：
影响因子：
8.3
通讯作者：
Williams,Olajide
中科院分区：
文献类型：
--
作者：
Willey,JoshuaZ;Williams,Olajide
Rinaldo等人的文章1描述了黑人/西班牙裔美国人中机械血栓切除术（MT）的使用率低于非西班牙裔白人。我同意作者的观点，即在美国卒中护理中存在显著差异，特别是与预防策略的关系。2这项研究的结果令人担忧，因为它表明黑人/西班牙裔中MT和静脉溶栓的使用率较低，尽管一些方法学问题限制了解释。本文的主要困难在于没有任何个体患者数据来确定是否存在不同种族的MT合格性。尽管作者根据可能与大血管闭塞相关的国际疾病分类第十版进行了分析，但这些代码尚未得到验证，许多患者可能使用其他非特异性国际疾病分类第十版代码（如I63）进行编码。9、当有大血管闭塞时。其他作者已经显示了种族-民族之间卒中亚型的显著差异，例如，白人的心源性栓塞病因率较高，部分原因是他们年龄较大。3本文作者没有按性别和种族描述所有住院患者的比例（表1），这可能有助于将卒中亚型纳入背景。表3中的结果很难遵循，因为表中的比例与结果不一致：例如，接受血栓切除术的黑人与白人相比，年龄> 80岁的比例为17.4%与12%，然而，句子表明他们不太可能> 80岁（17.2%与28.4%）。作者无法获得关于神经科医生裁定的亚型、大血管闭塞率或血栓切除术的医学资格的个体数据，并且没有明确解释大样本量如何纠正这一限制;相反，更大的样本量可能会加重这些混杂因素，在较小的研究中，这些混杂因素无统计学意义。值得注意的是，黑人/西班牙裔更有可能直接到达血管内中心，而白人的转移率更高。在不了解分支医院的基础人群以及他们是否按性别或种族不同转诊至血管内治疗中心的比率的情况下，纳入最有可能发生大血管闭塞的转移患者作为转移指征也是有问题的。然而，令人鼓舞的是，一旦患者接受溶栓治疗，血栓切除术的发生率在不同种族之间是相同的，这表明患者到达后提供治疗没有偏倚。导致重组组织型纤溶酶原激活剂使用频率降低的因素也与导致MT使用的因素相同，即院前延迟，包括症状识别，而不是医生或医疗机构的偏见。关于贫困和社会经济地位如何影响延迟到达医院的文献很多，这些延迟是急性卒中治疗率差异的主要驱动力。4然而，作者无法获得溶栓或MT信息的资格，特别是到达时间，这是另一个主要限制。作者指出，美国在急性卒中治疗方面存在种族差异，实际上，由于社会经济、性别和种族-种族因素以及不同的卒中亚型，持续延迟到达医院可能会扩大MT的获得差异。更多...
The article by Rinaldo et al1 describes the rates of utilization of mechanical thrombectomy (MT) among black/Hispanics being lower than non-Hispanic whites. I agree with the authors that significant disparities have been described in stroke care in the United States, particularly in relationship to prevention strategies. 2 The results of this study are concerning for demonstrating lower rates of use in MT and intravenous thrombolysis in blacks/Hispanics, although several methodological issues limit the interpretation. The primary difficulty in this article is that there is not any individual patient data to determine whether there was a differential eligibility for MT by race ethnicity. Although the authors performed an analysis based on an International Classification of Diseases, Tenth Revision that may be associated with a large vessel occlusion, these codes have not been validated and many patients may be coded with other nonspecific International Classification of Diseases, Tenth Revision codes such as I63. 9 when there is an large vessel occlusion. Other authors have shown significant differences in stroke subtyping by race-ethnicity, with whites, for example, having higher rates of cardioembolic etiologies in part due to their older age. 3 The authors in this article did not describe the proportions in all admissions (Table 1) by sex and race ethnicity which may have helped place into context stroke subtyping. The results in Table 3 were difficult to follow as the proportions in the table did not readily correspond to the results: for example, blacks undergoing thrombectomy versus whites had a proportion of age> 80 of 17.4% versus 12%, however, the sentence indicates that they were less likely to be> 80 (17.2% versus 28.4%). The authors did not have access to individual data on neurologist adjudicated subtyping, rates of large vessel occlusion, or medical eligibility for thrombectomy and there is no clear explanation how a large sample size would correct for this limitation; a larger sample size instead could accentuate these confounders which in smaller studies would be nonstatistically significant. It was also interesting to note that blacks/Hispanics were more likely to arrive to an endovascular center directly, while whites had higher rates of transfer. The inclusion of transfer patients, who are most likely to have an large vessel occlusion as an indication for transfer, is also problematic without understanding the basal population at the spoke hospital and whether they had different rates of referrals to endovascular centers by sex or race ethnicity. It was encouraging to see, however, that once patients were treated with thrombolysis that the rates of thrombectomy were the same by race ethnicity suggesting there is no bias in offering the treatment once patients arrive. The factors driving less frequent utilization of recombinant tissue-type plasminogen activator are also the same ones driving MT utilization, namely prehospital delays including symptom recognition rather than physician or healthcare facility biases. There has been significant literature on how poverty and socioeconomic status impact delayed arrival to the hospital, and these delays are a major driving force for differential rates of acute stroke treatment. 4 The authors, however, did not have access to eligibility for thrombolysis or MT information, notably arrival times, which is an additional major limitation. The authors point to the significant disparities existing in the United States by race ethnicity in acute stroke treatment, and indeed continued delayed arrival to the hospital due to socioeconomic, sex, and race-ethnicity factors, as well as different stroke subtypes, could widen disparities in access to MT. More …