What is the clinical evidence from this study?

Study design: Cohort. Population: End-Stage Renal Disease on long-term dialysis (n=265685). Intervention: African American race vs. White race. Primary outcome: Hemorrhagic stroke (ARR 1.43, 95% CI 1.30 to 1.57, p=<0.001).

What does this research mean for the field?

African American and Hispanic dialysis patients have a significantly higher risk for hemorrhagic stroke compared with whites, and these racial and ethnic differences largely explain state-by-state geographic variation in stroke rates. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

January 24, 2014

Race, Ethnicity, and State-by-State Geographic Variation in Hemorrhagic Stroke in Dialysis Patients

Q: What are the key findings of this study?

African American and Hispanic dialysis patients had a significantly higher risk for hemorrhagic stroke compared with whites (ARR 1.43 and 1.78, respectively), which largely explained state-by-state geographic variation in stroke rates.

Q: What does this research mean for the field?

African American and Hispanic dialysis patients have a significantly higher risk for hemorrhagic stroke compared with whites, and these racial and ethnic differences largely explain state-by-state geographic variation in stroke rates. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

JWJames B. WetmoreUniversity of Minnesota MPMilind A. PhadnisUniversity of Kansas Medical Center JMJonathan D. MahnkenUniversity of Kansas Medical Center

Resultado clave

African American and Hispanic dialysis patients had a significantly higher risk for hemorrhagic stroke compared with whites (ARR 1.43 and 1.78, respectively), which largely explained state-by-state geographic variation in stroke rates.

Diseño del estudio

Tipo

Cohort (n=265,685)

Multicéntrico

Sí

PICO estructurado

Does race and ethnicity explain state-by-state geographic variation in hemorrhagic stroke among incident dialysis patients?

Población

265,685 Medicare-eligible incident dialysis patients (≥18 years of age) in the United States, initiated long-term dialysis between January 1, 2000, and October 2, 2005, and survived at least 90 days. Mean age 64.7 years, 52.9% male.

Resultado

Hemorrhagic stroke (identified by ICD-9 codes 430 and 431)hard clinical

Race and ethnicity appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke among incident dialysis patients in the United States.

Resultado numérico

Estimación del efecto: ARR 1.43 (95% CI 1.30 to 1.57)

valor p: p=<0.001

Limitaciones

Outcomes were based on administrative claims rather than clinical data, lacking information on stroke severity or location.
The unit of geographic variation (state) was relatively large, preventing fine resolution analysis.
The primary analysis was restricted to individuals who were Medicare-eligible from the start of dialysis, limiting generalizability.
Lack of information on exposure to warfarin, an important hemorrhagic stroke risk factor.
Potential for residual confounding and competing risks inherent to observational studies.

Resumen

BACKGROUND AND OBJECTIVES: Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown. DESIGN, SETTING, PARTICIPANTS, 95% confidence interval CI, 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0. CONCLUSION: Race and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.

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