Racial Disparities in Utilization of Emergency Medical Services and Related Impact on Poststroke Disability

Abstract

Background: Prompt seeking of emergency medical services (EMS) assistance at stroke onset is critical to minimize poststroke disability. Objective: The aim was to study how racial differences in EMS decision-relevant factors and EMS use impact stroke care and disability outcomes. Design: A prospective observational study. Participants: A total of 1168 acute ischemic stroke patients discharged from April 2016 to October 2017 at a safety net hospital were included; 108 patients were surveyed before discharge. Measures: (1) Prehospital delay: EMS use, timely hospital arrival; (2) Stroke care: alteplase receipt and inpatient rehab; (3) Outcomes: Functional improvement at discharge (admission minus discharge scores on National Institutes of Health Stroke Scale), 90-day modified Rankin Scale; (4) EMS decision-relevant factors: Stroke symptom knowledge, source of knowledge, unfavorable past EMS/care experiences, and financial barriers to EMS use. Results: Despite more Black patients using EMS than Whites/Asians (56% vs. 48%, P=0.003), their timely hospital arrival was 30% less likely. Adjusted for stroke severity, receipt of alteplase, and inpatient rehab were similar, but Black patients fared worse on functional improvement at discharge (among severe strokes, 2.4 National Institutes of Health Stroke Scale points less improvement, P<0.01), and on functional normalcy at 90 days (modified Rankin Scale score 0–1 being 60% less likely across severity categories) (P<0.01). Fewer Black patients knew any stroke symptoms before the stroke (72% vs. 87%, P=0.03), and fewer learned about stroke from providers (P=0.01). Financial barriers and provider mistrust were similar. Conclusions: Black patients had less knowledge of stroke symptoms, more care-seeking delay, and poorer outcomes. Including stroke education as a standard of chronic disease care may mitigate stroke outcome disparities.