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Blacks Get Key Stroke Drug Less Often

Study finds big race gap in lifesaving treatment

THURSDAY, May 3 (HealthScout) -- Black stroke victims are up to five times less likely than whites to receive an effective but widely underused clot-dissolving drug that minimizes brain damage after the episodes, a new study says.

A survey of 42 teaching hospitals nationwide showed that while racial disparities in the use of the drug, called tissue-type plasminogen activator (TPA), vary by region, blacks on average receive the therapy far less often than whites.

TPA must be administered within about three hours of a stroke, and is only effective for ischemic attacks involving blood clots in the brain. But even in the smaller number of patients who are ideal candidates for TPA, whites are about three times more likely than blacks to receive the drug.

"I was quite surprised by the disparity we discovered, and I think a lot of physicians will be, too," says Dr. S. Claiborne Johnston, a neurologist at the University of California at San Francisco and lead author of the study, which appears in the May issue of the journal Stroke: Journal of the American Heart Association.

Blacks suffer more ischemic strokes than whites, and they're more likely to die from them, Johnston says. "But the degree of the disparity that we saw in our study is not accounted for by differences in the kinds of strokes. It's due to delivery" of care.

In one analysis of nearly 1,200 stroke patients, including 788 whites and 285 blacks, Johnston and his colleagues found that 49, or 4.1 percent, received TPA; only 1 percent of blacks took the drug, compared with 5 percent of whites.

Of the 189 patients considered prime candidates for the drug, 39, or about 21 percent, took it. Among this group, 8.3 percent of eligible blacks were prescribed TPA, compared with 24.6 percent of eligible whites.

In a wider look at national trends, the researchers also examined TPA use among 8,600 stroke patients at 66 hospitals, breaking the results down by geographic region and between medical centers.

Again, the results were surprising, says Johnston. "The Southeast seemed the ideal place to look for [racial disparity]" in the use of the drug, he says, but there was none. "Those old biases of ours don't really hold, at least not for this issue," Johnston says.

In the conventionally liberal Northeast, however, fewer than 1 percent of blacks received TPA, compared with 2.3 percent of whites. Similar splits cropped up in the West and Midwest.

Although subtle racial bias might explain the unequal treatment of black and white stroke patients, other factors could account for some of the discrepancy, Johnston says. Blacks took slightly longer than whites to get to the hospital after a stroke, though not significantly so. And blacks may be more suspicious of the treatments they're given, although the narrower analysis of 189 prime candidates for TPA found that none refused the drug when it was offered.

Insurance coverage undoubtedly plays a role, too, Johnston says, but in a yet unknown way. Patients on Medicaid, the government's low-income health plan, or people who lacked insurance, were 11 times less likely than those with coverage to receive TPA. On the other hand, Johnston says, TPA is universally under-reimbursed by insurers, regardless of the plan.

He says the insurance differences might reflect a general trend of better care for patients with better coverage. Hospitals in wealthy communities are more likely to serve wealthy patients with comprehensive policies, allowing them to support the newest and most advanced treatments.

"It's an alarming fact, but the real underlying reason isn't known," says Dr. David Wang, director of the OSF Stroke Network in Peoria, Ill., and author of an editorial accompanying the journal article.

Even so, Wang says that shouldn't preclude doctors from taking steps to reduce the racial disparity in TPA use. "That part we can do" without fully understanding the reasons for it, says Wang, who also is a clinical assistant professor of neurology and clinical pharmacology at the University of Illinois College of Medicine.

What To Do

To learn more about brain attacks, visit the National Stroke Association or try the National Institute of Neurological Disorders and Stroke.

Read other HealthScout articles about strokes.

SOURCES: Interviews with S. Claiborne Johnston, M.D., M.P.H., assistant professor of neurology, University of California, San Francisco, and David Z. Wang, D.O., director, OSF Stroke Network, clinical assistant professor of neurology and clinical pharmacology, University of Illinois College of Medicine, Peoria; May 2001 Stroke: Journal of the American Heart Association
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