Trends in Ethnic Disparities in Stroke Care and Long-Term Outcomes
Authors: Emmett Eva S. , O’Connell Matthew D. L. , Pei Ruonan , Douiri Abdel , Wyatt David , Bhalla Ajay , Wolfe Charles D. A. , Marshall Iain J. 
Published: January 2025

Importance

Reducing the burden of stroke is a public health priority. While higher stroke incidence among ethnic minority populations (defined in the context of this study as individuals who are not White) is well established, reports on ethnic inequalities in care or outcomes are conflicting and often limited to hospital-admitted patients and short-term outcomes.

Objective

To investigate ethnic differences in stroke care and outcomes up to 5 years after stroke and describe temporal trends and contributory factors.

Design, Setting, and Participants

This population-based cohort study enrolled participants from a geographically defined area of London, United Kingdom, with prospective follow-ups up to 5 years after stroke. Participants were adults with incident stroke in 1995 to 2021. Data were analyzed from May 2023 to October 2024.

Exposure

Self-reported ethnicity, categorized as Black African, Black Caribbean, White, or other (eg, Asian, other Black ethnicity, or multiple ethnicities).

Main Outcomes and Measures

Outcomes of interest were stroke unit admission, thrombolysis rate, functional outcomes (measured using Barthel Index and Frenchay Activities Index), and survival.

Results

Among 7280 patients (mean [SD] age, 69.3 [15.2] years; 3787 [52.0%] male) included, 3628 (63.2% of 3-month survivors) had 3-month follow-up data and 1951 (60.8% of 5-year survivors) had 5-year follow-up data. By ethnicity, 861 participants (11.8%) were Black African, 1089 (15.0%) were Black Caribbean, 4738 participants (65.1%) were White, and 592 participants (8.1%) identified as other ethnicity. Black African and Black Caribbean participants were younger than White participants (mean [SD] age, 59 [14] years, 68 [15] years, and 72 [14] years, respectively), with higher rates of hypertension (629 participants [75.0%], 805 participants [75.6%], and 2801 participants [61.8%], respectively), diabetes (246 participants [29.3%], 427 participants [40.2%], and 750 participants [16.5%], respectively), and body mass index greater than 25 (372 participants [69.0%], 370 participants [61.3%], and 1094 participants [51.6%], respectively). Black African and Black Caribbean participants had higher stroke unit admission rates than White participants in 1995 to 2003 (66 participants [42.6%], 129 participants [42.0%], and 573 participants [29.5%], respectively) but not thereafter. Black Caribbean participants had persistently lower thrombolysis rates (adjusted odds ratio compared with White participants, 0.56 [95% CI, 0.40-0.80]) and later hospital arrivals (arrival &amp;gt;4 hours after stroke onset: 217 Black African participants [53.8%]; 251 Black Caribbean participants [60.0%]; 654 White participants [51.2%]; P = .02). Black African and Black Caribbean participants had better survival than White participants (Black African participants: adjusted hazard ratio, 0.64 [95% CI, 0.54-0.77]; Black Caribbean participants: adjusted hazard ratio, 0.83 [95% CI, 0.74-0.94]) but poorer functional outcomes up to 5 years after stroke, with no significant changes over time.

Conclusions and Relevance

This cohort study found major and persistent ethnic inequalities in stroke care and outcomes, and these disparities were not fully explained by sociodemographic or stroke-related factors or the high vascular risk factor prevalence in Black African and Black Caribbean participants. Drivers of poor functional outcomes require further research, but cardiovascular health–checks should be considered for Black African individuals at younger ages, and late hospital arrivals and low thrombolysis rates in Black Caribbean individuals might be amenable to tailored health campaigns.