The impact of ethnicity on stroke care access and patient outcomes: a New Zealand nationwide observational study.

BACKGROUND

Ethnic inequities in stroke care access have been reported internationally but the impact on outcomes remains unclear. In New Zealand, data on ethnic stroke inequities and resultant effects on outcomes are generally limited and conflicting.

METHODS

In a prospective, nationwide, multi-centre observational study, we recruited consecutive adult patients with confirmed stroke from 28 hospitals between 1 May and 31 October 2018. Patient outcomes: favourable functional outcomes (modified Rankin Scale 0-2); quality of life (EQ-5D-3L); stroke/vascular events; and death at three, six and 12 months. Process measures: access to reperfusion therapies, stroke-units, investigations, secondary prevention, rehabilitation. Multivariate regression analyses assessed associations between ethnicity and outcomes and process measures.

FINDINGS

The cohort comprised 2,379 patients (median age 78 (IQR 66-85); 51·2% male; 76·7% European, 11·5% Māori, 4·8% Pacific peoples, 4·8% Asian). Non-Europeans were younger, had more risk factors, had reduced access to acute stroke units (aOR=0·78, 95%CI, 0·60-0·97), and were less likely to receive a swallow screen within 24 hours of arrival (aOR=0·72, 0·53-0·99) or MRI imaging (OR=0·66, 0·52-0·85). Māori were less frequently prescribed anticoagulants (OR=0·68, 0·47-0·98). Pacific peoples received greater risk factor counselling. Fewer non-Europeans had a favourable mRS score at three (aOR=0·67, 0·47-0·96), six (aOR=0·63, 0·40-0·98) and 12 months (aOR=0·56, 0·36-0·88), and more Māori had died by 12 months (aOR=1·76, 1·07-2·89).

INTERPRETATION

Non-Europeans, especially Māori, had poorer access to key stroke interventions and experience poorer outcomes. Further optimisation of stroke care targeting high-priority populations are needed to achieve equity.

FUNDING

New Zealand Health Research Council (HRC17/037).

Informations de copyright

© 2021 The Authors.

Déclaration de conflit d'intérêts

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no disclosures, except for DC, JD and JK who report grants from the Health Research Council of New Zealand during the conduct of the study; DC also reports grants from National Health and Medical Research Council, grants from Medtronic, grants from Amgen, grants from Stroke Foundation, grants from Academy of Science, grants from Heart Foundation, grants from CSIRO, grants from Victorian Agency for Health Innovation, grants from Boehringer Ingelheim, grants from Melbourne Health, grants from National Institute for Health Research UK, grants from Western Australian government, grants from South Australian government, outside the submitted work. MH reports an Appointed member of Waitemata District Health Board 2016 to 2019; no other relationships or activities that could appear to have influenced the submitted work.