Key result
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.
Why the study?
Does race and ethnicity explain state-by-state geographic variation in hemorrhagic stroke among incident dialysis patients?
Cohort (n=265,685)
Yes
Does race and ethnicity explain state-by-state geographic variation in hemorrhagic stroke among incident dialysis patients?
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.
May inform equitable stroke prevention in dialysis populations; leaves open causal mechanisms for geographic disparities.
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, & MEASUREMENTS: Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke. RESULTS: A total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 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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Wetmore et al. (2014) conducted a cohort in End-Stage Renal Disease on long-term dialysis (n=265,685). African American race vs. White race was evaluated on Hemorrhagic stroke (ARR 1.43, 95% CI 1.30 to 1.57, p=<0.001). 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.
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