Treatment Disparities in Stroke and Atrial Fibrillation Study

Acute ischemic stroke (AIS) is a devastating consequence of atrial fibrillation (AF), which is preventable with oral anticoagulants (OACs). The goal of this study was to evaluate contemporary trends and disparities in OAC use at hospital discharge in patients with AIS and AF in the era of direct oral anticoagulants (DOACs).

Transitions of Care Stroke Disparity Study

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The TCSD Study identifies disparities in transitions of stroke care and key factors associated with effective transitions of care through structured telephone interviews to evaluate medication adherence, healthy lifestyle, utilization of rehabilitation interventions and medical follow-up 30 days after hospital discharge to home and in-patient care rehabilitation in 2,400 participants across 12 comprehensive stroke centers (CSC) in Florida. A novel Transitions of Stroke Care Performance Index (TOSC PI) is being derived and validated. The primary outcomes are the TOSC PI and 90-day readmission. Other stroke outcomes include stroke disability, recurrence, cardiovascular events, and death at 3 months. Outcomes are collected through telephone interviews and review of patient charts. Predictors of disparities in transition of care and outcomes are evaluated using baseline in-hospital data during acute stroke hospitalization obtained from the Florida Stroke Registry and Social Determinants of Health obtained through novel data collected from publicly available records. Based on identified predictors of disparities in TOSC, we will develop and demonstrate feasibility of initiatives for interventions to reduce disparities in TOSC that target systems of care with a TOSC disparities dashboard, and health care providers with a training module for enhanced education and support at discharge and during follow-up. We evaluate any temporal improvements in the TOSC Performance Index and outcomes before and after the interventions.

Disparities and Temporal Trends in the Use of Anticoagulation in Patients With Ischemic Stroke and Atrial Fibrillation


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Ischemic stroke (IS) secondary to atrial fibrillation (AF) is largely preventable with the use of anticoagulation. We sought to identify race-ethnicity and sex disparities with the use of direct oral anticoagulants (DOACs), aspirin, and warfarin in IS patients with AF and to identify temporal trends in the utilization of these medications. The FLiPER-AF Stroke Study (Florida Puerto Rico Atrial Fibrillation) included 24 040 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin, and warfarin for stroke prevention in AF after adjustment for sociodemographic, hospital, and clinical factors. Results- Among 24 040 IS cases, 54% were women and 10% black, 12% FL-Hispanics, 4% PR-Hispanic, and 74% whites. From 2010 to 2016, DOAC use increased from 0% to 36%, warfarin use decreased from 51% to 17%, and aspirin use remained relatively stable (42%-40%). After adjustment, blacks had higher odds of warfarin (odds ratio, 1.22; 95% CI, 1.07-1.40) prescription at discharge compared with whites. Men had higher rates of aspirin (42.1% versus 38.8%), warfarin (33.6% versus 28.9%), and DOAC (21.3% versus 19.3%) use compared with women. After adjustment, women had lower odds of being discharged on aspirin (odds ratio, 0.92; 95% CI, 0.86-0.98) or warfarin (odds ratio, 0.91; 95% CI, 0.84-0.99). There was no sex difference in use of DOACs. Conclusions- Our study confirmed the increasing use of DOACs, downtrending use of warfarin, whereas aspirin use remained similar over the years. There are sex and race-ethnicity disparities in anticoagulation use in IS patients with AF. It is critical to understand underlying drivers of these disparities to develop better practice strategies for stroke prevention in patients with AF.

Florida-Puerto Rico Collaboration to Reduce Stroke Disparities

In 2009, the total direct and indirect cost of stroke and cardiovascular disease is estimated to be more than $312 billion. The financial and emotional burden of stroke and cardiovascular disease is greater among African Americans and Hispanics given that they are at greater risk than other groups of common risk factors like hypertension, diabetes, obesity, and metabolic syndrome.

The Florida Puerto Collaboration to Reduce Stroke Disparities (FL-PR CReSD) aims to address stroke disparities among African Americans and Hispanics and to identify the best approaches to eliminate stroke care disparities in these groups.

The specific goals of the FL-PR CReSD include:

The creation of a voluntary Florida Puerto Rico Stroke Registry among Florida and Puerto Rico hospitals currently participating in the American Heart Association’s quality improvement initiative Get With The Guidelines Stroke.

  • Evaluation of disparities in stroke care performance metrics by race, ethnicity, and geographic regions.
  • Analysis of the frequency of disparities at 30-days after a stroke in terms of outcomes (mortality, hospital readmission, stroke recurrence) medication adherence, and lifestyle modifications by race, ethnicity and geographic regions.
  • Evaluation of the frequency of disparities in longer-term outcomes (mortality, hospital readmission, stroke recurrence) among Medicare patients within the Florida Puerto Rico Stroke Registry and the relationship of such outcomes with acute stroke performance metrics.
  • Implement education programs among healthcare stakeholders with a focus on identifying and implementing specific culturally-tailored quality improvement programs to address disparities.