Ethnic Disparities in Acute Stroke Presentation and Reperfusion Therapy in a Dutch Comprehensive Stroke Center

This single-center study found that patients with a migration background in a Dutch stroke center were more likely to present outside the therapeutic time window and receive lower rates of endovascular thrombectomy compared to patients without a migration background, despite having similar in-hospital treatment times.

The Gist

The "Emergency Lane" Gap: Why Some Stroke Patients Get to the Finish Line Slower Than Others

Imagine a high-stakes Formula 1 race. When a car crashes, there is a very specific, tiny window of time where a pit crew can jump in, fix the engine, and get the car back on the track. If the crew arrives too late, the car is too damaged to save.

In the world of medicine, a stroke is that crash. The "pit crew" is the hospital team, and the "repair" is called reperfusion therapy (using medicine or tiny tools to clear a blockage in the brain). To win the race—to save the patient's ability to speak, walk, and live independently—the crew has to act incredibly fast.

A recent study conducted in the Netherlands looked at whether everyone is getting the same "pit crew" service, or if some drivers are being left on the track longer because of their background.

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The Study: Checking the Race Stats

Researchers looked at 232 patients who had their first ischemic stroke (a blockage in the brain). They divided them into two groups: those with a "migration background" (people born outside the Netherlands or with parents born outside) and those without.

They wanted to see if there was a difference in three things:

1. The Arrival Time: How quickly did they get to the hospital?
2. The Repair Kit: Did they get the advanced treatments (like IV drugs or mechanical tools to clear the blockage)?
3. The Pit Stop Speed: Once they arrived, how fast did the doctors actually start the treatment?

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The Findings: A Tale of Two Laps

1. The "Late Start" Problem

The study found that patients with a migration background were nearly twice as likely to arrive at the hospital outside the "golden window" of treatment.

The Analogy: Imagine two runners. One runner starts the race at the starting gun. The other runner, due to a series of unexpected hurdles—perhaps not knowing exactly when the race started, or feeling hesitant to join the track—doesn't show up until the race is already halfway over. Because they started late, they are much harder to "fix."

2. The "Toolbox" Disparity

The researchers found a significant gap in a high-tech treatment called EVT (a procedure where doctors use a tiny device to physically pull a clot out of the brain). Patients with a migration background were much less likely to receive this advanced "tool."

The Analogy: It’s as if the pit crew had two types of toolboxes. One group of cars received the high-tech, laser-guided repair kit, while the other group only received the basic wrench. The study suggests this might be because the "crash" (the stroke) looked different in these patients—they had different types of blockages that were harder to catch with the standard tools.

3. The "Pit Crew" Speed

Interestingly, once the patients actually arrived at the hospital, the doctors worked at roughly the same speed for everyone. There wasn't a "slow lane" inside the hospital itself.

The Analogy: This means the "mechanics" (the doctors) weren't being slow on purpose. The problem wasn't the speed of the tools once they were in the garage; the problem was that some cars were arriving at the garage much too late, or they were arriving with different types of damage that didn't trigger the high-tech repairs.

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The Big Picture: Why Does This Matter?

The study concludes that we can't just focus on making hospitals faster; we have to look at what happens before the patient reaches the hospital doors.

To close this gap, we need to understand the "hurdles" that keep certain groups from getting to the hospital in time. Is it a language barrier? Is it a lack of awareness about the symptoms? Is it a lack of trust in the medical system?

The Goal: We want to make sure that no matter who you are or where you come from, when your "engine" fails, the pit crew is ready, the tools are available, and the race can be won.

Technical Summary

Technical Summary: Ethnic Disparities in Acute Stroke Presentation and Reperfusion Therapy

Problem

While acute reperfusion therapies—intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)—have significantly improved functional outcomes for ischemic stroke patients, global literature suggests significant disparities in their administration. Existing research, primarily from the United States and New Zealand, indicates that ethnic minorities often present later to emergency departments and receive lower rates of reperfusion therapy. However, there is a lack of data regarding these disparities within European healthcare systems, specifically in the Netherlands, where the healthcare landscape (e.g., universal insurance and geographic density) differs from the US.

Methodology

The researchers conducted a single-center observational cohort study at the Haaglanden Medical Center (HMC), a comprehensive stroke center in the Netherlands.

• Study Population: 232 patients with a first-ever ischemic stroke were included (from a larger study cohort between September 2020 and September 2021).
• Categorization: Patients were divided into two groups: those with a migration background (born outside the Netherlands or having at least one parent born outside the Netherlands) and those without a migration background.
• Data Collection: Data were extracted from medical records and digital questionnaires, covering sociodemographic characteristics (age, sex, education, comorbidities), stroke characteristics (NIHSS score, TOAST etiology), and treatment metrics.
• Primary Outcomes:
  1. Timing of hospital presentation (proportion presenting outside the therapeutic window).
  2. Use of acute reperfusion therapy (IVT and EVT).
  3. In-hospital treatment times (Door-to-Treatment Time [DTTT], Door-to-Needle Time [DTNT], and Door-to-Groin Time [DTGT]).
• Statistical Analysis: Univariable and multivariable logistic regression (for binary outcomes) and linear regression (for continuous treatment times) were used. Models were adjusted for age, sex, and NIHSS score to account for potential confounding.

Key Contributions

• First Dutch Contextualization: This is the first study in the Netherlands to specifically investigate ethnic disparities in acute stroke reperfusion, including the modern standard of care, EVT.
• Etiology-Linked Analysis: The study provides insight into how differences in stroke etiology (e.g., higher prevalence of small-vessel disease in migrant populations) may influence the eligibility and administration of specific treatments like EVT.
• Healthcare System Comparison: By finding no significant differences in in-hospital treatment times, the study contributes to the understanding of how universal healthcare and compact geography may mitigate certain systemic disparities seen in other nations.

Results

• Presentation Timing: Patients with a migration background were significantly more likely to present outside the therapeutic time window (53.2% vs. 37.1%; adjusted OR 1.90; 95% CI 1.05–3.45).
• Reperfusion Therapy:
  • There was a significant disparity in EVT rates: patients with a migration background received EVT much less frequently than those without (8.1% vs. 22.4%; adjusted OR 0.28; 95% CI 0.10–0.75).
  • No statistically significant difference was found in the administration of IVT (32.3% vs. 38.2%).
• Stroke Etiology: Patients with a migration background had a higher prevalence of small-vessel disease (69.4% vs. 48.2%) and a lower prevalence of cardio-embolism (4.8% vs. 15.3%) and large-artery atherosclerosis.
• In-Hospital Efficiency: There were no significant differences in in-hospital treatment times (DTTT, DTNT, or DTGT) between the two groups.

Significance

The study highlights a critical gap in stroke care: while the Dutch hospital system appears efficient in delivering treatment once a patient arrives (no disparity in in-hospital times), there is a significant pre-hospital barrier for patients with a migration background, leading to delayed presentation. This delay, combined with a higher prevalence of small-vessel disease (which is less likely to require EVT), contributes to lower rates of advanced reperfusion therapy. The findings suggest that to achieve true equity in stroke care, interventions should focus on improving stroke recognition and reducing barriers to timely hospital presentation within migrant communities.