Racial & Ethnic Disparities in Incidence and Inpatient Outcomes of Acute Stroke

描述(由申请人提供)：目前关于中风的种族和民族差异的大部分文献都来自于白人和少数民族的比较。为了确定这些差异背后的关键可改变因素，我们提出了一种替代方法，该方法遵循以下认识：在每个种族和民族亚群中，中风(缺血性和出血性)的发病率和结果存在巨大差异。黑人的发病率更高或结果更差的原因可能与西班牙裔不同。作为初步论证，我们使用了新泽西州和亚利桑那州(2002-2004)所有住院患者的数据来检查急性缺血性中风的发病率。非西班牙裔白人、非西班牙裔黑人和西班牙裔分别被分成三个收入类别-较低、中等和较高收入类别；每个队列的年龄-性别调整后的急性中风发病率。一个非常令人费解的发现是，在这两个州，高收入群体的拉美裔美国人的中风发生率系统性地更高。相比之下，黑人和白人的收入梯度是向下倾斜的。这种方法的用处一目了然。在新泽西州和亚利桑那州，拉美裔美国人的额外中风发生率(相对于同收入的白人)在低收入人群中为25%，在高收入人群中为200%。因此，拉美裔美国人的高发病率风险可能较少是由于与SES相关的潜在因素(有限的保险、低收入、公共援助、医生供应)，而更多是由于潜在因素，如生理风险因素(糖尿病、肥胖、高血压)、健康行为(吸烟、锻炼)、风险意识、地理位置和提供者相关特征。将分析限制到每个种族/民族亚组，我们的目标是确定和评估哪些潜在因素会影响三个种族和民族亚组的中风发病率和不良住院结局的“额外”风险。我们建议使用九个州(亚利桑那州、加利福尼亚州、佛罗里达州、马萨诸塞州、新泽西州、纽约州、宾夕法尼亚州、南卡罗来纳州和德克萨斯州)2005-2007年间所有住院患者出院的数据，这些州都有相当大的少数民族人口。发病率将通过合并每个队列的人口普查人口来获得。采用负二项、Logistic和线性分层多元回归模型，估计各潜在因素的影响程度。公共卫生相关性：自20世纪60年代以来，中风发病率的减少和急性中风护理的进步一直是中风死亡率稳步下降的重要因素。最近几年的一个令人担忧的问题是，这种下降已经趋于平缓。第二个担忧是，这些收益在种族、民族和社会经济地位之间的分配不成比例。为了有效地确定干预措施和公共政策的目标，我们的研究旨在使用证据来确定适合每个少数民族队列的可修改因素并确定其优先顺序。

DESCRIPTION (provided by applicant): Most of the current literature on racial and ethnic disparities in stroke comes from comparing whites with minorities. To identify key modifiable factors underlying these disparities, we propose an alternative approach that follows from recognizing that there is immense diversity in stroke (ischemic and hemorrhagic) incidence and outcomes within each racial and ethnic subpopulation. Factors underlying higher incidence or worse outcomes for blacks may be different than those for Hispanics. As a preliminary demonstration, we examined incidence of acute ischemic stroke using data of all inpatient admissions in New Jersey and Arizona (2002-2004). Non- Hispanic whites, non-Hispanic blacks and Hispanics were each stratified into three income categories - lower, middle and higher; age-sex adjusted acute stroke incidence rates were obtained for each cohort. A remarkably puzzling - and to the best of our knowledge previously unreported, finding is that in both the states, the stroke rate for Hispanics was systematically higher for higher income groups. In contrast, the income gradients for blacks and whites were downward sloping. The usefulness of this approach is immediately apparent. In New Jersey and Arizona, the excess stroke rate (relative to same-income whites) for Hispanics is 25 percent for lower income cohort but 200 percent for higher income cohort. Therefore higher incidence risk among Hispanics may be less due to SES-related potential factors (limited insurance, low income, public assistance, physician supply) and more due to potential factors such as physiological risk factors (diabetes, obesity, hypertension), health behavior (smoking, exercise), risk awareness, geographic location and provider-related characteristics. Limiting analysis to each racial/ethnic subgroup, our objective is to identify and assess which potential factors influence "excess" risk of stroke incidence and adverse hospital outcomes for the three racial and ethnic subpopulations. We propose to use data on all inpatient discharges during 2005-2007 from nine states (AZ, CA, FL, MA, NJ, NY, PA, SC and TX), with sizable minority populations. Incidence rates will be obtained by combining Census populations of each cohort. Hierarchical multivariate regression models negative binomial, logistic and linear, will be used to estimate the influence of each potential factor. PUBLIC HEALTH RELEVANCE: Reductions in stroke incidence and advancements in care for acute stroke have been instrumental in the steady declines in stroke mortality since the 1960s. One concern in recent years is that this decline has leveled. A second concern is that these gains have been disproportionately distributed across race, ethnicity and socioeconomic status. For effective targeting of interventions and public policy, our study aims to use evidence to identify and prioritize modifiable factors appropriate for each minority cohort.