The issue of barriers to care for immigrants is particularly relevant in the context of stroke, given two new studies. One study reported that Mexican-Americans were 57 percent more likely than non-Hispanic whites to have a second stroke within a year of their first stroke (Ann Neurology 2006;Epub 22 August 2006). The second study concluded that the high incidence of ischemic stroke among Hispanics and other minority groups would contribute to an enormous economic burden over the next several decades (Neurology 2006; Epub 16 August 2006).
HIGHER RECURRENT STROKE RATES
The Annals of Neurology study, led by Lynda D. Lisabeth, PhD, Assistant Professor of Epidemiology at the University of Michigan in Ann Arbor, MI, reported that a higher incidence for recurrent stroke for Mexican-Americans persisted even after the investigators adjusted for other vascular risk factors, first stroke severity, and demographics. Additionally, stroke recurrence was significantly associated with a two-to-three-times higher risk of death due to any cause.
While previous studies have shown an increased risk of ischemic stroke for Mexican-Americans, especially at younger ages (Am J Epidemiol 2004;160:376–383), this was the first study to assess and compare their risk of stroke recurrence and the effect of recurrence on mortality with non-Hispanic whites.
Dr. Lisabeth and colleagues noted that Mexican-Americans have a higher likelihood of diabetes, obesity, inactivity, and hypertension than non-Hispanic whites. Mexican-Americans are also less likely to recognize and report hypertension as a risk factor (Stroke 2004;35:1557). The study authors called for further study of the reasons for the disparities in stroke recurrence.
REASONS FOR DISPARITIES
Other experts, who were not involved in this study, weighed in. “Limited [health care] access is the likely cause of higher stroke and risk for stroke recurrence in Mexican-Americans,” Edgar J. Kenton, III, MD, Director of the Stroke Prevention/Intervention Research Program at Morehouse College in Atlanta, told Neurology Today. He noted that many Mexican-Americans have “limited or no insurance coverage and, in rural areas, have limited access to hospitals, particularly adequate stroke centers.”
“This is a well-done study that adds to the growing evidence on the increased stroke burden among Hispanic populations,” said Ralph L. Sacco, MD, Head of the Stroke and Critical Care Division at Columbia University in NY. Dr. Sacco added that “socioeconomic differences, access to care, social supports, medication compliance, other unmeasured vascular risk factor differences, or genetic factors could affect these disparities.” Insufficient resources to cover prescriptions and education, as well as access to preventative health care, “may lead to inadequate detection and control of stroke risk factors,” he said.
THE ECONOMIC BURDEN
And what about the projected costs of stroke among minority groups as compared with non-Hispanic whites? The Neurology study, led by Devin L. Brown, MD, and colleagues of the University of Michigan and Columbia University, projected that the total cost of stroke from 2005 to 2050, in 2005 dollars, would be $1.52 trillion for non-Hispanic whites, $379 billion for African-Americans, and $313 billion for Hispanics.
The per capita costs of stroke were highest in African-Americans ($25,782), followed by Hispanics ($17,201), and non-Hispanic whites ($15,597).
S. Claiborne Johnston, MD, PhD, Director of the University of California-San Francisco Stroke Service, called the Neurology study stroke rates estimates “reasonable, unless we see substantial reduction in rates going forward because of improvements in treatments.” Dr. Johnston, who was not involved in the study, noted that the $2.2 trillion dollar cost citation assumes that “stroke rates won't be decreasing due to better prevention strategy, and it certainly should provide additional motivation to ramp up prevention efforts.”
Dr. Johnston said he would like to see money spent on understanding why proven interventions [e.g., blood pressure control] are not being used and what can be done to increase utilization. He continued, “The science behind the implementation of proven therapies is tragically under-funded and the benefits of research in this area are likely to be monumental.”
• Lisabeth LD, Smith MA, Morgenstern LB, et al. Ethnic differences in stroke recurrence. Ann Neurology
2006: Epub 22 August 2006.
• Brown DL, Boden-Albala B, Morgenstern LB, et al. Projected costs of ischemic stroke in the United States. Neurology
2006; Epub 10 August 2006.