National Evaluation of Racial, Ethnic, and Insurance-Based Disparities in Interhospital Transfer of Patients With Ischemic Stroke

BACKGROUND: Disparities in interfacility transfer of patients with acute ischemic stroke have been identified at the regional level, but a national analysis has not been conducted. This study aims to evaluate patient-level trends and disparities in transfer rates based on sex, race, ethnicity, and insurance status using the Get With The Guidelines-Stroke registry. METHODS: The Get With The Guidelines-Stroke registry was used to identify patients admitted with acute ischemic stroke between January 2016 and December 2021. We examined patient transfer rate by race/ethnicity groups and by patient insurance status. Odds of transferring out among each demographic group were calculated using a multivariable generalized linear mixed-effect model accounting for patient- and hospital-level confounders. Models were stratified by sex to test for any potential interaction between sex and race/ethnicity or insurance status. RESULTS: Among 776 556 patients transferred out of 1333 sites, Hispanic and Black patients had lower odds of being transferred compared with non-Hispanic Whites among both males and females after adjustment for stroke severity and hospital characteristics (odds ratio OR, 0.79 95% CI, 0.74-0.84 for Hispanic females; OR, 0.88 95% CI, 0.83-0.93 for Hispanic males; OR, 0.80 95% CI, 0.76-0.83 for Black females; and OR, 0.84 95% CI, 0.81-0.88 for Black males). Differences in transfer frequency were also noted based on insurance status. In the unadjusted model and model adjusted for stroke severity, patients of all non-Medicare payment groups had higher odds of being transferred out compared with Medicare patients. However, after also adjusting for hospital characteristics, patients with Medicaid had a lower frequency of transfer compared with patients with Medicare among males and females (OR, 0.75 95% CI, 0.71-0.78 for females with Medicaid; OR, 0.78 95% CI, 0.75-0.82 for males with Medicaid). CONCLUSIONS: In this large, nationwide cohort of patients with acute ischemic stroke, Black and Hispanic patients were less likely to be transferred than non-Hispanic White patients, and patients with Medicaid were less likely to be transferred than patients with Medicare. Further work is needed to understand the contributors to this disparity and the impact on access to high-quality stroke care.