Come Prepared

On March 17-18, 2022, the National Institute of Neurological Disorders and Stroke (NINDS) will host a virtual symposium titled Inequities in Access and Delivery of Acute Stroke Care. The goal of the symposium is to present an overview of current equity issues, known and unknown causes or obstacles, and best practices or possible solutions concerning stroke care.

Symposium presentations were informed by diverse, multidisciplinary teams of public health and stroke experts, who voluntarily participated in a series of steering committee, task force, and subgroup meetings leading up to the symposium. Each task force focused their research review on one of three time epochs of stroke care: prehospital, hyper/acute, and inpatient. During these meetings, participants identified key disparities and their root causes, potential solutions and best practices, remaining knowledge or research gaps, and tangible actions over both the short- and long-term to address inequities.

In addition to informing the symposium itself, the data and conclusions amassed will culminate in a written report. We encourage all symposium participants to review the draft report (see PDF below) ahead of next week’s event.

Do you have an idea you’d like to contribute? During the symposium, we welcome your participation, feedback, and new ideas on how to make stroke care accessible and equitable to all.

Although extensively detailed in the draft report, the key findings and recommendations of each task force can be summarized as follows:

  • In the prehospital setting, inequities and disparities exist in the utilization of emergency medical services (EMS), stroke treatment rates, recognition of stroke signs and symptoms among prehospital providers and the public, diversity of EMS professionals, and stroke awareness.
  • To address these issues, the task force recommends:
    • Stroke systems of care need to consider geographic networks that are optimally designed for specific rural, urban, or suburban region.
    • Stroke leaders should work with their state and local regulators to assess stroke training needs among prehospital care providers to standardize care in a region.
    • Expand telestroke systems of care into the prehospital setting.
    • Modify EMS reimbursement models to appropriately reflect and align with the complex decision-making that occurs with potential stroke patients in the prehospital setting.
    • Link prehospital patient care reports with hospital patient care reports and outcomes.
    • Establish a national stroke registry and national stroke standards for prehospital care.
    • Enhance registry data at state and local levels to better identify existing disparities and opportunities for improvement.
    • Expand and enhance culturally sensitive sustainable stroke messaging to the public.
    • Promote EMS workforce diversity.
  • In the hyperacute and acute setting—moments prior to hospital arrival until definite hospital admission—inequities and disparities exist in access to higher-level stroke hospitals (in both initial arrival and timely transfer), providers with sufficient educational resources to maintain expertise and engage with diverse patient populations, access to and/or standardized use of telemedicine, and low research participation by hospitals and patients, particularly in rural settings.
  • To address these issues, the task force recommends:
    • Incorporation of Mobile Interventional Stroke Team (MIST) models to improve initial and transfer access, particularly outside of urban settings.
    • Improvement, standardization, and expansion of educational resources and support to providers to ensure sufficient expertise and increased diversity of the workforce.
    • Uniform licensing and with national and state-wide guidelines, infrastructure, and training for telemedicine adaptation.
  • In the inpatient care setting, inequities exist in access to post-stroke rehabilitation services, and there are disparities in the utilization of implantable cardiac monitors, compliance with early initiation of antithrombotic and statin therapy, and prescribing secondary stroke prevention therapies at hospital discharge.
  • Overall, there is limited data on inequities in diagnostic and therapeutic utilization during inpatient hospitalization for stroke.
  • To address these issues, the task force recommends:
    • Identifying existing disparities in inpatient prescribing (i.e., early antithrombotic administration) and discharge prescribing of secondary stroke prevention medications by evaluating:
      • Ethnicity/race and geography interaction.
      • Patient education, income, health insurance coverage.
    • Standardizing terminology and categories (i.e., education level, income, insurance, and geography or residential area). A possible solution is to require researchers to use NINDS Common Data Elements.
    • There are significant gaps in knowledge. Patient level factors such as non-adherence, provider level factors like inaccurate assessment of risks/ benefits, therapeutic inertia, or societal level factors (i.e., drug cost, referral patterns, etc.) need to be better defined.
    • Research is needed to determine how best to facilitate the community navigation necessary to encourage positive health outcomes for individuals transitioning back into low-resourced rural communities.
    • Additional research is needed to assess which characteristics of rurality are most salient to the inpatient and post-stroke care experience.