Effects of System-Level Factors on Race/Ethnic Differences in In-Hospital Mortality after Acute Ischemic Stroke.
Effects of System-Level Factors on Race/Ethnic Differences in In-Hospital Mortality after Acute Ischemic Stroke.
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系统级因素对急性缺血性中风后院内死亡率种族/民族差异的影响。
DOI：
10.1101/2023.10.20.23297343
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发表时间：
2023
期刊：
影响因子：
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通讯作者：
Towfighi,Amytis
中科院分区：
文献类型：
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作者：
Sun,Philip;Markovic,Daniela;Ibish,Abdullah;Faigle,Roland;Gottesman,Rebecca;Towfighi,Amytis
简介中风死亡率有所下降，不同种族的变化有所不同；中风现在是总体死亡的第五大原因，但也是黑人的第二大死亡原因。关于急性缺血性卒中 (AIS) 后院内死亡率的近期种族/族裔和性别趋势以及系统水平因素是否导致可能的差异，人们知之甚少。方法使用全国住院患者样本，确定了 2006 年至 2017 年初步诊断为 AIS 的成年人（≥18 岁）（n=643,912）。我们按种族/民族（白人、黑人、西班牙裔、亚裔/太平洋岛民 [API]、其他）、性别和年龄评估了院内死亡率。医院按非白人患者就诊比例进行分类：<25%（“主要是白人患者”）、25-50%（“混合种族/族裔特征”）和≥50%（“主要是非白人患者”）。使用调查调整逻辑回归，评估种族/族裔与死亡率之间的关联，并调整关键的社会人口统计学、临床和医院特征（例如年龄、合并症、中风严重程度、不复苏命令和姑息治疗）。结果总体而言，死亡率从 2006 年的 5.0% 下降到 2017 年的 2.9%（p<0.001）。与 2006-2011 年相比，2012-2017 年与 2006-2011 年相比，调整协变量后死亡率总体下降了 68%，其中在白人中最显着（69%），在黑人中最小（57%）。与白人患者相比，黑人和西班牙裔患者的死亡率较低（调整后比值比 (aOR) 0.82，95% CI 0.78–0.87 和 aOR 0.93，95% CI 0.87–1.00），主要由 65 岁以上患者驱动（年龄 x 种族交互作用 p < 0.0001）。与白人男性相比，黑人、西班牙裔和 API 男性以及黑人女性的死亡率 aOR 较低。与混合医院（aOR 0.85，0.79-0.91）和主要为非白人患者服务的医院（aOR 0.88，0.81-0.95；交互作用：p=0.005）相比，白人和非白人患者之间的死亡率差异在主要为白人患者服务的医院（aOR 0.80，0.74-0.87）最为明显。种族/民族亚群体。总体而言，非白人 AIS 患者的死亡率低于白人患者，这一差异在主要为白人患者服务的医院中最为显着。需要进一步的研究来了解这些差异以及生物、社会文化和系统层面的因素在多大程度上发挥作用。
IntroductionStroke mortality has declined, with differential changes by race; stroke is now the 5th leading cause of death overall, but 2nd leading cause of death in Black individuals. Little is known about recent race/ethnic and sex trends in in-hospital mortality after acute ischemic stroke (AIS) and whether system-level factors contribute to possible differences.MethodsUsing the National Inpatient Sample, adults (≥18 years) with a primary diagnosis of AIS from 2006 to 2017 (n=643,912) were identified. We assessed in-hospital mortality by race/ethnicity (White, Black, Hispanic, Asian/Pacific Islander [API], other), sex, and age. Hospitals were categorized by proportion of non-White patients served: <25% (“predominantly White patients”), 25–50% (“mixed race/ethnicity profile”), and ≥50% (“predominantly non-White patients”). Using survey adjusted logistic regression, the association between race/ethnicity and odds of mortality was assessed, adjusting for key sociodemographic, clinical, and hospital characteristics (e.g., age, comorbidities, stroke severity, do not resuscitate orders, and palliative care).ResultsOverall, mortality decreased from 5.0% in 2006 to 2.9% in 2017 (p<0.001). Comparing 2012–2017 to 2006–2011, there was a 68% reduction in mortality odds overall after adjusting for covariates, most prominent in White individuals (69%) and smallest in Black individuals (57%). Compared to White patients, Black and Hispanic patients had lower odds of mortality (adjusted odds ratio (aOR) 0.82, 95% CI 0.78–0.87 and aOR 0.93, 95% CI 0.87–1.00), primarily driven by those >65 years (age x ethnicity interaction p < 0.0001). Compared to White men, Black, Hispanic, and API men, and Black women had lower aOR of mortality. The differences in mortality between White and non-White patients were most pronounced in hospitals predominantly serving White patients (aOR 0.80, 0.74–0.87) compared to mixed hospitals (aOR 0.85, 0.79–0.91) and predominantly non-White hospitals (aOR 0.88, 0.81–0.95; interaction effect: p=0.005).DiscussionAIS mortality decreased dramatically in recent years in all race/ethnic subgroups. Overall, non-White AIS patients had lower mortality than their White counterparts, a difference that was most striking in hospitals predominantly serving White patients. Further study is needed to understand these differences and to what extent biological, sociocultural, and system-level factors play a role.