Structural Racism and Discrimination in the Expansion of Hospital Stroke Care Capacity: A Multi-Level Analysis on Access to Care, Treatment, and Outcomes

Although advances in the treatment of stroke have significantly decreased morbidity and mortality for stroke patients in the United States, there is a growing disparity in the provision of stroke services between disadvantaged populations and others. No studies have examined the role of structural racism and discrimination (SRD) in the expansion of stroke care capacity across communities and subsequent effects on health disparity patients. The long-term goal of this project is to identify system-level pathways in the delivery of acute stroke care that contribute to the growing disparities for NIH-designated health disparity populations (defined as racial/ethnic minority, low-income, and rural patients). The overall objective is to determine the mechanisms through which health disparity patients experience SRD in stroke care.
Using national data from 2009 to 2019, we propose three aims to test the following hypotheses: Aim 1, That disadvantaged communities (defined as segregated areas with high shares of health disparity populations) experience differential adoption of levels of stroke care, resulting in increased disparities in potential access to care relative to other communities. Aim 2, That health disparity patients in segregated communities experience increased disparities in actual access and treatment due to patient redistribution across hospitals with different levels of stroke care and differential treatment within hospitals. Aim 3, That individuals in disadvantaged communities and health disparity patients experience widening disparities in health and functional outcomes.
In Aim 1, we will identify which types of disadvantaged communities, if any, were left behind in gaining stroke care access, and whether racial or ethnic segregation and income inequality contribute to these structural disparities in geographic access. These results will aid certification bodies to consider incorporating community need in certification guidelines. In Aim 2, our results will illuminate patient redistribution patterns in communities that gain access to stroke care and pinpoint patients who experience disparities in actual access and treatment depending on their race, ethnicity, and income as well as the level of segregation in each of those dimensions. Results will identify the types of communities where outreach might be most effective in reducing disparities in stroke care. In Aim 3, our results will determine the extent of health disparities among stroke patients a) between disadvantaged and non-disadvantaged communities after adoption of stroke care, compared to communities with no change; and b) between health disparity and other patients within the same community when those communities experience changes in stroke care, relative to those in communities with no change in access to stroke care. These findings will identify specific communities where additional interventions (e.g., mobile stroke units, enhancing telehealth access) could yield the greatest benefits.