|ORIGINAL CONTRIBUTION: PREVENTIVE EPIDEMIOLOGY IN NEUROLOGY
|Year : 2014 | Volume
| Issue : 1 | Page : 9-16
Stroke burden and risk factors during 1997-2008: Examining the effect of ethnicity and gender
Baqar A Husaini1, Robert Levine2, Van Cain1, Meggan Novotny1, Jan Emerson1, Gail Orum3, Mohsen Bazargan3, Pamela Hull4, Muhib Khan5, Majaz Moonis5
1 Tennessee State University, Nashville, Tennessee, USA
2 Meharry Medical College, Nashville, Tennessee, USA
3 Charles Drew University, Los Angeles, California, USA
4 Vanderbilt University, Nashville, Tennessee, USA
5 University of Massachusetts, Massachusetts, USA
|Date of Web Publication||3-May-2014|
Prof. Baqar A Husaini
Box 9580 Tennessee State University, 3500 John Merritt Blvd. Nashville, TN 37209,
Source of Support: The analysis for this article was supported by a Grant from CDC Grant no. U58CCU422782 to Tennessee Department of Health (subcontract no. ED-07-20811-00 to Tennessee State University, B. Husaini, PI). Additional support for Levine, Husaini, and Cain was also provided by another NIH grant # P20-MD000516 (National Center on Minority Health and Health Disparity to Meharry Medical College)., Conflict of Interest: None
Objective: Examine the effect of race and gender variation on the burden of stroke and associated risk factors among hospital-discharged patients. Materials and Methods: We examined Tennessee Hospital Discharge Database from 1997 to 2008 for patients (older than 20 years) discharged with a diagnosis of stroke. The number of stroke patients was 17,149 in 1997; 19,020 in 2003; and 17,010 in 2008. We also extracted data on cardiovascular risk factors for each patient. Age-adjusted prevalence of hospitalization for stroke per 100K for non-Hispanic white and black patient groups was developed per Center of Disease Control (CDC) procedures of at-risk population. Race- and gender-specific prevalence of stroke and associated cardiovascular risk factors among hospitalized patients were examined using multivariate logistic models. To examine consistency, we compared the two groups at three different points: 1997, 2003, and 2008 regarding the prevalence of stroke and their associated risk factors. Results: Our analyses revealed three major trends: (1) Age-adjusted stroke rate declined by 13.8% over a 12-year period (from 466.8 per 100,000 in 1997 to 402.2 per 100,000 in 2008). This decline occurred for both black and white patients. However, the white stroke rate declined by 19.8% (from 401.9 in 1997 to 322.2 in 2008), compared with only 13.7% among blacks (from 599.2 in 1997 to 517.3 in 2008). Additionally, throughout the 12-year period, although no significant gender differences were observed, the stroke rates among blacks remained consistently higher compared with whites (black:white rate ratios of 1.60 in 1997, 1.40 in 2003, and 1.60 in 2008). Logistic regression analysis revealed the four risk factors that consistently predicted stroke for both black and white patients in 1997, 2003, and 2008, namely, hypertension (HTN), diabetes mellitus (DM), high cholesterol, and cardiac arrhythmia. Conclusion : Aggressive management of two cardiovascular risk factors (HTN and DM) may subsequently reduce stroke health disparity and the burden of stroke hospitalization among blacks.
Keywords: Gender, race, risk factors, stroke rates, stroke
|How to cite this article:|
Husaini BA, Levine R, Cain V, Novotny M, Emerson J, Orum G, Bazargan M, Hull P, Khan M, Moonis M. Stroke burden and risk factors during 1997-2008: Examining the effect of ethnicity and gender. Astrocyte 2014;1:9-16
|How to cite this URL:|
Husaini BA, Levine R, Cain V, Novotny M, Emerson J, Orum G, Bazargan M, Hull P, Khan M, Moonis M. Stroke burden and risk factors during 1997-2008: Examining the effect of ethnicity and gender. Astrocyte [serial online] 2014 [cited 2023 Dec 1];1:9-16. Available from: http://www.astrocyte.in/text.asp?2014/1/1/9/131855
| Introduction|| |
Stroke is the fourth leading cause of mortality in Americans. Recent evidence suggests that every 40 seconds, someone in the United States experiences stroke and that approximately 800,000 Americans experience stroke each year. Moreover, nearly one-fourth of strokes are recurrent strokes. Additionally, stroke rates are increasing among younger adults (age < 45 years), whereas rates among older persons have somewhat stabilized. Finally, while more women than men are affected by stroke each year, reasons for the gender difference in incidence rates remain unclear. Recent reports indicate that stroke rates are declining but mortality remains higher in some minority groups. ,,,,,,,,,,,,,,,,,,,,,
Ethnic groups constitute a large portion of the American population. Among these groups, African Americans (blacks) account for nearly 13% of the nation's population. To provide quality care, there is an ever-growing need for providers to have an enhanced understanding of the complex impact of race and gender on stroke and chronic conditions (comorbidities) that contribute to lower life expectancy in the black population. , Since previous studies of stroke covered only shorter periods of time, this article examined a 12-year data (1997-2008) of hospitalized stroke patients with three focal points of comparison: (1) beginning period in 1997, (2) mid-period in 2003, and (3) ending period in 2008. Persistent trends that emerge across the three periods will add to the robustness of our findings. Thus, within this larger span of time, we evaluated consistency of our findings with regard to three questions: (1) Are there changes in the prevalence of stroke hospitalization over a 12-year period, (2) Are there persistent racial and gender differences in stroke morbidity, and (3) Are the stroke risk factors similar across three points of comparison, namely, 1997, 2003, and 2008?
| Materials and Methods|| |
We used Tennessee Hospital Discharge Data System (HDDS) to obtain relevant data on adult patients (older than 20 years) from 1997 to 2008. Patients from the Veteran Administration Hospitals, as well as, mental health hospitals are excluded from the HDDS data. Furthermore, the HDDS data are administrative files compiled by the Division of Health Statistics (Tennessee Department of Health). These administrative files provide patients' age, gender, race/ethnicity, county of residence, postal zipcode, date of admission/ discharge, admitting and discharge principal and secondary diagnoses (ICD-9 codes), principal procedure codes, and total ($) charges. These files do not provide data pertaining to patients' marital status, education, or annual income. All diagnoses are given by the attending physicians and the diagnoses appear only when the patients are treated for those diagnoses. No clinical data are provided either for tests performed or symptom indices used in arriving at clinical judgments/diagnoses.
This study used patients' primary discharge diagnosis of stroke (ICD-9 codes of 430-438). Although an individual may appear several times in a year, in our analysis the individual appears only once in any one year. Since 97% of Tennessee population constitutes non-Hispanic whites and blacks, our analysis is only confined to black and white comparisons. Data extracted from the HDDS files also included presence or absence of comorbidities such as hypertension (HTN), diabetes mellitus (DM), cardiac arrhythmia (CA), and other chronic conditions affecting the patient.
Prevalence for hospitalization of stroke (per 100,000) were directly age-adjusted and indexed to the year 2000 census per methodology provided by Center For Disease Control and Prevention (CDC) for the population at risk. Prevalence of comorbidities prevalence of comorbidities by race and gender were evaluated with Fisher's exact test. Percentages of stroke per discharge in each period were compared using a Pearson correlation and Chi-square tests with the Yates correction for continuity, and odd ratios were obtained through logistic regression analyses with age, HTN, DM, and other risk factors in the model.
| Results|| |
Changes in Stroke Morbidity over 12 years
Our analyses indicate that the prevalence of stroke among hospitalized patients in Tennessee has declined by 13.8% over the 12-year period (from 466.8 per 100,000 in 1997 to 402.2 per 100,000 in 2008). This decline occurred for both black and white patients [Figure 1]. The white stroke prevalence declined by 19.8% (from 401.9 in 1997 to 322.2 in 2008), whereas the decline among blacks was limited to only 13.7% over 12 years (from 599.2 in 1997 to 517.3 in 2008). Furthermore, stroke prevalence declined by 18.3% among males (from 498.9 in 1997 to 407.8 in 2008), whereas females had a smaller decline of 9.7% (from a rate of 442.2 in 1997 to a rate of 399.1 in 2008). The greater decline among males is largely reflective of a greater decline in stroke among whites. Finally, black males and black females show smaller declines (12.5% and 14.2%, respectively) compared with stroke declines among white females (20.7%) and white males (19.3%).
|Figure 1 a-b: Age-adjusted Stroke Rates and Rate Ratio Per 100K by Race, Age 18+, 1997-2008.|
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Stroke Morbidity by Race
[Figure 1] also indicates that for each year, the stroke prevalence (per hospitalized patients) was significantly higher among blacks compared with whites (and this is reflected by a higher black:white unadjusted rate ratios of 1.50 in 1997, 1.40 in 2003, and 1.60 in 2008). These higher rate ratios favoring blacks were confirmed by significant adjusted odd ratios in logistic models [significant odds ratio (OR) of 1.06, 95% confidence interval (CI) (1.01-1.11) in 1997; OR of 1.16, 95% CI (1.12-1.21) in 2003, and OR of 1.31, 95% CI (1.26-1.37) in 2008]. These adjusted ORs suggest that rates for blacks were consistently higher than whites despite controlling for comorbidities that jointly contributed to stroke rates at three points of comparisons. In sum, these adjusted ORs clearly indicate a higher burden of stroke among blacks despite the adjustments for the related comorbidities.
Stroke Morbidity by Gender
[Figure 2] shows that prior to year 2000, males had higher stroke rates than females. However, these gender differences disappeared after year 2000 for 8 years (2000-2008). This rate equalization suggests that females tended to have better outcomes starting in 2000 and this improvement (gender parity) continued through 2008. Recent evidence also provides support for the overall gender stroke parity. 
|Figure 2 a-b: Age-adjusted Stroke Rates and Rate Ratio per 100K by Sex, Age 18+, 1997-2008.|
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However, when race was controlled in the analytical model for 2008 data, a within-gender stroke disparity was observed. Here, black females had worse outcomes compared with white females (rate of 505.7 per 100,000 among black females vs. 298.9 per 100K among white females (OR = 1.29, 95% CI = 1.22-1.36). The black-white differences among females were particularly noticeable among younger females (aged 20-54 years; see [Table 1], cols. 6, 12, 18) where the stroke prevalence for younger black females was at least two times higher (2:1) compared with same-age white females. These ratios spiral downward after the age of 65 years resulting in no racial differences (ratio of 0.94) at age 85 years. Similar results were obtained for black males (see [Table 1], cols. 5, 11, 17) where stroke prevalence was at least two times higher (2:1) for younger black males (age 18-54 years) compared with same-age whites peers in 2008 in [Table 1] (OR = 1.31, 95% CI = 1.23-1.39). Clearly, stroke burden among hospitalized patients is higher among blacks under the age of 54 years (both females and males) compared with their same-age white peers.
|Table 1: Stroke Rates and Rate Ratios by Ethnicity, Sex, and Age: 1997, 2003, 2008|
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Stroke Morbidity and Age
[Table 2] shows that at three points of comparison (ie, 1997, 2003, 2008), the proportion of younger adults (age < 64 years) with stroke has steadily increased from 28% in 1997 to nearly 35% in 2008 [marking an increase of 25% among younger adults compared with a decline of 9.7% among the older adults (age >65 years)]. The proportion of younger adults (age < 64 years) experiencing stroke between 1997 and 2008 was significantly higher among blacks compared with whites (41% vs. 15%, P < 0.000), which also reflects increasing burden of stroke among younger blacks.
|Table 2: Stroke Percentages, Rates and Ratios by Age, Ethnicity, and Sex: 1997, 2003, 2008|
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The racial disparity is further evident when black:white ratios are examined. [Table 2] (cols. 2, 6, 9) shows that the younger blacks (20-54 years of age) have more than twice (2.5:1) the prevalence of strokes compared with whites at each point of comparison (1997, 2003, 2008). Effects of race, however, are diminished when only male versus female comparisons are examined. Hence [Table 2] (cols. 12, 15, 18) shows a stroke gender parity for younger age. The black:white ratios ([Table 2], cols. 12, 15, 18) between males and females remained almost equal for younger age (<54 years) throughout each point of comparison.
Stroke Risk Factors
[Table 3] (cols. 1-9) shows that at each point of comparison (1997, 2003, 2008), blacks have both a higher stroke prevalence along with a higher prevalence of HTN, DM, and CA compared with whites. Furthermore, at each comparison point, HTN and DM were persistently higher among blacks than whites.
|Table 3: Comorbidities of Stroke Patients by Ethnicity and Sex: 1997, 2003, 2008|
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We used multivariate logistic models to determine persistent risk factors for each racial group separately. [Table 4] shows that HTN, DM, high cholesterol, and CA significantly predicted stroke for both black and white patients consistently in 1997, 2003, and 2008. Both myocardial infarction and congestive heart failure (which existed among some of our patients) did not predict the onset of stroke. These findings support previously reported findings of risk factors, including atrial fibrillation. ,, Obviously, it is the higher prevalence and combined burden of these risk factors that contribute to higher stroke morbidity among blacks compared with whites. ,, No consistent patterns of risk factors emerged by gender since males and females included both black and white patients [[Table 3], cols. 10-18].
|Table 4: Odds Ratios and 95 % Confidence Interval of Risk Factors Predicting Stroke by Ethnicity: 1997, 2003, 2008|
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| Discussion|| |
Our analyses indicate that stroke prevalence among patients discharged from Tennessee hospitals declined between 1997 and 2008. Although declines occurred among both blacks and whites, white declines exceeded those for blacks and declines for males exceeded those for females. Although stroke gender differences have been inconsistent, recent evidence shows a greater gender stroke parity.  Throughout this period, the largest stroke decline has been among white females followed by white males, black females, with the lowest decline occurring among black males.
Given the higher prevalence of stroke among blacks, it is clear that racial disparities in stroke morbidity has persisted over 12 years, which indicates that blacks have persistently experienced higher stroke burden compared with whites. These findings are from a single southern state, and to what extent they mirror the stroke disparities in other geographic areas of the country remains unclear. However, our findings appear to be consistent with those reported by Northern Manhattan (New York) , and greater Cincinnati (Ohio) investigators.  The Cincinnati area study provided similar results of higher Black: white stroke ratios particularly among blacks of various ages: A ratio of 2.05 in <34 years of age, 4.18 in those 35-44 years of age, 2.02 ratio among 45-54 years of age, 1.74 ratio among 55-64 years of age, and 1.66 in those 65-74 years of age.  In our study, similar black:white ratios of stroke emerged by age [Table 2]. Although our data did not specifically analyze the incidence of recurrent strokes, previous studies have reported a higher risk of recurrent stroke among blacks compared with whites (2.4:1).  Furthermore, having DM (which existed among more than one third of our study population) significantly increases the risk of stroke for all adults (age <65 years) regardless of race. These findings as well as CDC mortality data , further substantiate lower black life expectancy  and greater burden of stroke among blacks than whites.
Stroke disparity results from a number of factors, including number of comorbidities, access to healthcare providers, awareness of stroke symptoms, and age. Age plays a significant role in that younger individuals may perceive themselves to be in good health despite having latent chronic conditions, such as high blood pressure, which may produce an end-stage cardiac event. Our data provide some evidence for such a perspective in that, on average, the black stroke patients were younger compared with whites (68 years vs. 74 years, respectively) and that the higher stroke rates among younger blacks (age <54 years, both males and females) suggest that they might have been unaware of how their HTN combined with other comorbidities was impacting their lives.
In addition to comorbidities, other factors such as access to health care providers, adherence to medical regimen, and awareness of stroke symptoms may contribute to stroke disparity. Evidence suggests that only 40% of the population recognizes stroke symptoms and activates emergency response systems. However, awareness and recognition of stroke symptoms among blacks and use of emergency services is far less compared with whites. ,,, Results of a recent Baltimore study indicated that blacks who experienced and recognized stroke symptoms waited for a friend to take them to the emergency department (ED) instead of calling 911. 
Stroke disparity can be improved through management of risk factors. Our study has revealed two major risk factors, HTN and DM, which are more prevalent among black than white patients. Blacks in other studies have also been found to have other risk factors such as left ventricular hypertrophy (LVH), smoking, and physical inactivity together with higher rates of DM and hypertension. ,, In some of these studies, DM and HTN have persistently emerged as independent risk factors for all ethnic groups, including the North Manhattan Study (NOMAS ),  as these risk factors have also affected a higher proportion of black than white patients in this study.
Previous studies have pointed to poor management of these risk factors in blacks. They have, for example, reported poor control of HTN despite adequate treatment. , Adherence to medical regimen is not only low for HTN and DM, but also for dyslipidemia as blacks are less likely to achieve lipid goals compared with whites. ,, Similarly, prophylactic use of aspirin and warfarin is low among blacks compared with whites. ,
It may be noted that low adherence to medication regimens could in part be related to low socioeconomic status (SES). According to the 2010 census figures, 25.8% of black families compared with 11.6% of white families, live below the poverty level.  The poor economic status of blacks may result in their inability to afford medications and hence discontinuation of treatment.  Low SES also contributes to low health literacy that translates into difficulties with following instructions, lack of self-empowerment, and distrust of new information. 
Access to health care is a major reason for higher morbidity and mortality in blacks. Blacks have longer wait times in the ED, , and lower specialty care, lower rates of referral from neurologists (10.6% among blacks vs. 20.3% among whites), and they (blacks) are 3.7 times less likely to receive intravenous thrombolysis in the EDs compared with those with referrals. ,,
Since our study examined data from a southern state, the findings require replication from other geographic areas to further substantiate the complex relationship between race and stroke, which permeates through gender, affecting black women negatively. To reduce these racial disparities, we need a better understanding of underlying factors such as genetic, biological, and SES that play a significant role in the onset and management of stroke. Because deficiencies in the health care system also contribute to stroke disparities, new population-based interventions targeting HTN and DM are needed to help reduce the racial divide in stroke outcomes. Such interventions aimed at reducing stroke may include educational programs that promote stroke symptom awareness, medication adherence, and lifestyle modifications including physical activity (simply walking more), which all together may contribute to lowering stroke morbidity and mortality in the underserved minority populations. ,,,,,
| Conclusion|| |
Stroke rates have declined over 12 years from 1997 to 2008. Despite the decline, rates have remained significantly higher for blacks compared with whites, particularly among younger blacks than < 54 years. No gender differences existed in stroke morbidity during the years of analysis. Risk factors associated with these rates are HTN, DM, CA, and cholesterol. Blacks have higher rates of HTN and DM, which contribute to significant stroke racial disparity. These comorbidities among blacks call for community-based primary prevention programs that may increase stroke symptom awareness and recognition, and improved management of comorbidities through lifestyle changes, increased physical activity, lower salt intake, and increased adherence to medical regimen. Such interventions may reduce stroke disparity that has persisted over 12 years.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]