Introduction: Prior investigation has shown that private insurance is associated with greater odds of transfer to a stroke center, potentially contributing to disparities in access to endovascular thrombectomy (EVT). Our objective was to examine the relationship between insurance status, race/ethnicity, and access to EVT. Methods: We used statewide data maintained by the California Department of Healthcare Access and Information to identify all encounters for acute ischemic stroke in the state from 2015-2021. Outcomes of interest were 1) presentation to an EVT-capable hospital (performed > 2 EVT during year of presentation), 2) transfer to an EVT-capable hospital (among patients initially presenting to a non-EVT capable hospital), 3) discharge from an EVT-capable hospital (among all patients), and 4) receipt of EVT (among all patients). We used hierarchical logistic regression models to examine the interaction between insurance and race/ethnicity with the outcome of interest, after adjusting for other covariates. To address small cell size, insurance and race/ethnicity were collapsed into 4 groups, non-Hispanic white vs. all other racial/ethnic groups and privately insured and Medicare patients vs. Medicaid and uninsured patients. Results: We identified 309,238 encounters for ischemic stroke, among whom 152,777 (49.4%) presented to an EVT-capable hospital, 13,500 (4.4%) were transferred to an EVT-capable hospital, 160,971 (52.1%) were discharged from an EVT-capable hospital, and 16,256 (5.3%) received EVT. In adjusted models, non-Hispanic white patients in the private insurance or Medicare group had significantly higher odds of presenting to an EVT-capable hospital than any other group. Relative to white patients with private insurance or Medicare, nonwhite patients with Medicaid or no insurance had lower odds of transfer to an EVT-capable hospital. There was no significant difference in adjusted odds of discharge from an EVT-capable hospital or receipt of EVT by race/ethnicity and insurance (Table). Conclusions: Relative to non-Hispanic white patients with private insurance or Medicare, all other groups had lower adjusted odds of presentation to an EVT-capable hospital. However, there were no differences in discharge from an EVT-capable hospital or receipt of EVT. These findings suggest that, while these groups may be less likely to have EVT-capable hospitals nearby, interhospital transfers mitigate geographic differences in access to EVT.
Messac et al. (Thu,) studied this question.