Disparities in acute stroke care delivery: equality or equity from stroke systems improvement?

Disparities persist in acute stroke care delivery, posing challenges to achieving equitable access and outcomes. The IMPROVE Stroke Care program aimed to enhance stroke care delivery by implementing best practices across a regional consortium. In this sub-analysis, we investigate whether these interventions improved stroke care equity. We analyzed data from 21,647 stroke code activations and evaluated for differential improvement in thrombolytic and thrombectomy treatment times, EMS use, and outcome measures over the course of the study with regards to gender, race/ethnicity, age, and insurance status. Disparities in baseline median door-to-needle (DTN) times between racial groups (Black 56 minutes vs White 48 vs Other 40; p=0.035) decreased during the study, with Black patients achieving similar treatment times as others by the end of the program (EOP) (Black 39 minutes, White 40, Other 40; p=0.478). Similar equitable improvements were observed for DTN times in uninsured patients (baseline uninsured 57 minutes vs Medicare 45, Medicaid 53 min, private/VA insurance 57 min; p=0.023; EOP uninsured 49, Medicare 45, Medicaid 47, private/VA 45; p=0.227), door-to-groin (DTG) times for thrombectomy amongst Black patients (baseline Black 232 minutes, White 74, Other 70, p=0.035; EOP Black 11, White 55, Other 34, p=0.015), and DTG times for uninsured patients (baseline uninsured median DTG 153 minutes, Medicare 85, Medicaid 78, private/VA 84, p=0.030; EOP uninsured 90 minutes, Medicare 85, Medicaid 106, private/VA 90, p=0.261). Both men and women showed equally improved thrombolytic treatment rates during the study. However, women initially experienced worse outcomes compared to men (discharge to home or acute rehab 75.5% vs 83.1%; 90-day mRS<340.8% vs 57.3%) but reached parity with men by EOP (81.8% vs 83.1%; p=0.037 and (48.1% vs 51.8%; p=0.990). In some measures, particularly in EMS utilization and pre-hospital notification, general equal improvements were noted for most groups, but underlying inequity failed to improve. This analysis underscores that collaborative, evidence-based interventions to improve stroke care at the regional level may also increase the equity of care delivery. Ongoing detailed and regionalized data collection and evaluation are essential to ensure sustained progress towards achieving equity for all stroke patients.