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Accessible Stroke Care for Diverse Populations: The Montefiore Approach

NeurologyLive, October 2021, Volume 4, Issue 5

SAP Partner | <b>Montefiore Health System</b>

Years of built-up trust in the community has enabled Montefiore’s Stern Stroke Center physicians to understand more about how stroke affects multicultural communities and to break down existing barriers to care.

This piece is part of our Gold Standard Centers feature series. For more of the series, click here.

IN THE HEART OF THE BRONX, NEW YORK, lies Stern Stroke Center at Montefiore—a leader in stroke services and care with an emphatic mission to provide quality access, raise stroke awareness, and improve poststroke outcomes in diverse populations.

According to a 2020 census report, the Bronx is primarily made up of individuals identifying as Hispanic, accounting for 56% of the population; Black (29%); and White (9%). Of the 1,418,207 people in the borough, 26.4% live below the poverty line, almost double the rate for the state of New York (13%) and more than double that of the United States. Additionally, 33.7% of the population are foreign born, about 1.5 times the rate of New York and more than double the rate of the United States.1

The stroke-related disparities these individuals face have been well documented. Notable research from Rinaldo et al found that the utilization of mechanical thrombectomy (7% vs 9.8%; P < .001) and likelihood of receiving intravenous tissue plasminogen activator (16.2% vs 20.5%; P < .001) was lower for Black/Hispanic patients than for White/non-Hispanic patients.2

Understanding the demographics of patients presenting to the stroke center is critical to the approach of care. “The personal challenges are never-ending when it comes to a high-risk community,” Charles C. Esenwa, MD, director at Montefiore’s Comprehensive Stroke Center (Stern Stroke Center), and an assistant professor of neurology at Albert Einstein College of Medicine, told NeurologyLive®.

“That can look different depending on where you are. For example, for inner-city, high-risk communities where we work, these are typically Black and Brown communities that are poor, impoverished, and lower on the circuit of socioeconomic status, and have a lot of social determinants of health,” Esenwa continued. “These social determinants of health are by-products of socioeconomic status and poverty but overlap greatly with race because of the nature of race in the United States.”

Esenwa specializes in vascular neurology with a particular interest in acute stroke management and stroke prevention strategies in highrisk individuals. His research focuses on acute stroke management, stroke risk factors, secondary stroke prevention, and stroke disparities. He believes that its access to a diverse community is part of what gives Montefiore an advantage in tackling these disparities.

“Because we have such a diverse community, we’re able to get to the bottom of these differences: why are there differences in race and are those differences genetic—which is what some people were proposing—or are [they] truly independent of genetic makeup and…more to do with social status,” Esenwa said.

The center treats more than 1400 patients with acute stroke per year, making it the second busiest stroke center in New York state.3 Many of the stroke experts on staff at the center are multilingual, which helps build communication and trust among those within a culturally different environment.

“Montefiore has a track record of doing good by the community,” Esenwa added. “There’s already a level of trust that’s been built up over the course of years of providing a high level of care to communities that aren’t necessarily getting that high level of care.”

Esenwa, who is from a non-White background, explained that the diversity of the hospital staff also plays a positive role in easing the process for patients. “It’s important to have people that represent the community in the hospital. Our Black, Latinx, gender nonconforming, and [female] patients—are they being represented in the medical staff? When I approach a patient who’s had a stroke [at our center], I can relate to them. That has to do with representation on our teams,” he said.

Accessibility to stroke care at all stages has become more of an issue for these communities in recent years but remains an area of concern overall. Results of research presented at the American Stroke Association (ASA) International Stroke Conference 2021 showed that although endovascular therapy (EVT) utilization has increased across all racial/ethnic groups since the treatment was validated in 2015, disparities are still present. Black patients were 32% less likely to receive EVT before 2015 and remained 17% less likely to receive it from 2015 on.4

“Although we deliver state-of-the-art stroke care that includes cutting-edge surgical and interventional procedures, we still make a point…of having the stroke faculty immediately available to patients,” Daniel L. Labovitz, MD, MS, medical director of Montefiore Comprehensive Stroke Center, and an assistant professor at Albert Einstein School of Medicine, told NeurologyLive®.

Labovitz’s research focuses on racial, ethnic, and social disparities in stroke incidence and outcomes, as well as the incidence and determinants of intracerebral hemorrhage and stroke-related epilepsy. He and Esenwa’s most recent research involved the effect of race on composite thrombotic events in patients with COVID-19. Using a multiracial cohort, they found no significant race-specific differences in thrombotic events.5

“It’s very clear it’s not a genetic predisposition, it’s a socioeconomic predisposition,” Esenwa said regarding the study, “whether that’s a frontline worker who must go to work because they can’t use Zoom, or it’s because they live with 4 or 5 people in their household and that puts them at risk, or because they live in a dense neighborhood with a lack of resources. Those are the things that put people at a higher risk of dying.”

These social determinants of health [that typically Black and Brown communities experience] are by-products of socioeconomic status and poverty, but overlap greatly with race because of the nature of race in the United States.”
—CHARLES C. ESENWA, MD

Again, Esenwa attributes the diverse community as a vehicle to understanding racial disparities and where they stem from, whether that be genetics, a view that has been traditionally imposed, or socioeconomic status, which has been highlighted in recent years. In 2017, Labovitz was an investigator on a study that examined racial/ethnic disparities in hospital arrival times among 1790 patients with acute ischemic stroke who presented to a tertiary-case hospital in the Bronx. The cohort consisted of 338 Caucasians, 662 Hispanics, and 790 African Americans. At the conclusion of the study, a greater proportion of Hispanic and African American women than Caucasian women (74% and 72% vs 59%, respectively) had delayed hospital arrival times (≥ 3 hours) after the onset of stroke symptoms. However, this racial/ ethnic difference was no longer present after adjusting for socioeconomic status.6

In addition to access of care, Labovitz noted that individuals’ overall awareness and knowledge of stroke needs improvement. The center has tried reaching out to schools as well as working with community leader Olajide A. Williams, MD, MS. Williams, a professor and chief of staff of the Department of Neurology at Columbia University Vagelos College of Physicians and Surgeons, developed a public health campaign that uses hip hop music to teach children how to identify stroke symptoms. He was able to show that elementary school students are educable about stroke, retain their knowledge well, and may be able to appropriately activate emergency services for acute stroke.7,8

Nearly 30% of US adults younger than 45 years don’t know all 5 of the most common stroke symptoms, according to the ASA. Hispanic adults and adults not born in the United States are about twice as likely to be unaware of any of the common stroke symptoms compared with non-Hispanic White people and those born in the country.9

“One problem with stroke is that it doesn’t hurt. Heart attacks hurt. You get chest pains, you become uncomfortable, you seek help. Stroke mostly doesn’t hurt. It’s possible for someone to get the symptoms of a stroke and wait for their daughter to come home instead of seeking any help because they think it’s going to go away,” Labovitz said.

The center has reached out to individuals within the community to try to raise awareness of and combat these knowledge gaps. Additionally, it provides stroke support groups dedicated to educating patients and their families. Montefiore has also opened its doors to the community for World Stroke Day, a worldwide initiative that takes place on October 29 each year to increase awareness and drive action on stroke prevention.

“We recognize that this is beyond just a one-person issue [and that it is] a population-level issue,” Esenwa said. “We work closely with organizations like the American Heart Association to get the word out about stroke recognition and using BE FAST.” BE FAST— Balance, Eyes, Face Drooping, Arm Weakness, Speech Difficulty, and Time to call 911—helps individuals remember the signs of stroke and what to do if someone is experiencing them.

Stroke recognition, especially among the younger population, is another area in which the center has concentrated significantly. Usually considered as something that occurs in older individuals, stroke has become more prevalent among younger adults, with literature suggesting that about 10% to 15% of strokes occur in those aged 18 to 50 years.10 A county-by-county analysis found that between 2010 and 2016, strokes among middle-aged people had increased 3 times as much as strokes in people over the age of 64 years. Notably, these statistics were not confined to the “Stroke Belt,” a swath of the southeastern United States where stroke rates are between 2 and 4 times the national average.11

Esenwa was a senior author of a retrospective study published earlier this year that gained insights into the presence or absence of cardiovascular risk factors in cases of cryptogenic stroke in adults aged 18 to 49 years. These patients had higher rates of hypertension, intracranial atherosclerosis, and diabetes mellitus. Upon admission, they also demonstrated higher glucose HbA1c levels, blood pressure, and cholesterol compared with patients with cardioembolic acute ischemic stroke. The investigators concluded that half of young patients with cryptogenic stroke fit the risk factor phenotype of small and large vessel strokes.12

“We came up with this notion that it’s not the rare stuff you should be looking for in the youth, it’s the typical stuff that you should be looking for,” Esenwa said about the data. “Just look for the uncontrolled version of the typical stuff. That understanding shifts the narrow view of stroke in the young to a broader view that’s inclusive of communities like ours. It also opens doors to look at it from a preventive standpoint.”

Looking forward, the center remains committed to its research efforts and goals of understanding more about how social determinants of health affect multicultural communities. According to Esenwa, once this information is more regularly recorded, Montefiore can then implement additional programs to treat these high-risk individuals.

“We pride ourselves on being just like everybody else in the sense that we are held to very strict standards,” Labovitz concluded. “The stroke community has worked incredibly hard over the past 2 decades to share best practices, establish standards of care, and set benchmarks for rapid delivery of care. And Montefiore is right in the thick of it. What’s special about us, though, is that we deliver this state-of-the-art care in an incredibly humane and kind way.”

REFERENCES
1. Bronx County, NY. Census Reporter. 2019. Accessed September 24, 2021. https://censusreporter.org/ profiles/05000US36005-bronx-county-ny/
2. Rinaldo L, Rabinstein AA, Cloft H, Knudsen JM, Castilla LR, Brinjikji W. Racial and ethnic disparities in the utilization of thrombectomy for acute stroke. Stroke. 2019;50(9):2428-2432. doi:10.1161/ STROKEAHA.118.024651
3. The Stern Stroke Center at Montefiore. Montefiore. Accessed September 24, 2021. https://www. montefiore.org/sternstrokecenter
4. Sheriff F, Cruz-Flores S, Fonarow GC, et al. National temporal trends in endovascular therapy (EVT) utilization and outcomes according to race and ethnicity: findings from Get With the Guidelines (GWTC)-stroke. Abstract presented at: International Stroke Conference 2021; March 17-19, 2021; Virtual. Abstract LB 9.
5. Esenwa C, Unda SR, Altschul DJ, et al. The effect of race on composite thrombotic events in patients with COVID-19. Thromb Res. 2021;199:10-13. doi:10.1016/j.thromres.2020.12.015
6. Springer MV, Labovitz DL, Hochheiser EC. Race-ethnic disparities in hospital arrival time after ischemic stroke. Ethn Dis. 2017;27(2):125-132. doi:10.18865/ed.27.2.125
7. How Columbia’s “Hip Hop Doc” is raising stroke awareness. Columbia University Irving Medical Center. July 11, 2013. Accessed September 24, 2021. https://www.cuimc.columbia.edu/news/ how-columbias-hip-hop-doc-raising-stroke-awareness
8. Williams O, Noble JM. ‘Hip-hop’ stroke: a stroke educational program for elementary school children living in a high-risk community. Stroke. 2008;39(10):2809-2816. doi:10.1161/STROKEAHA.107.513143
9. Nearly one in three young adults in the US does not known common stroke symptoms. News release. American Heart Association. October 26, 2020. Accessed September 24, 2021. https://newsroom.heart.org/news/ nearly-one-in-three-young-adults-in-the-u-s-does-not-know-common-stroke-symptoms
10. George MG. Risk factors for ischemic stroke in younger adults: a focused update. Stroke. 2020;51(3):729-735. doi:10.1161/STROKEAHA.119.024156
11. Hall EW, Vaughn AS, Ritchey MD, Schieb L, Casper M. Stagnating national declines in stroke mortality mask widespread county-level increases, 2010-2016. Stroke. 2019;50(12):3355-3359. doi:10.1161/STROKEAHA.119.026695
12. Dardick JM, Flomenbaum D, Labovitz DL, Cheng N, Liberman AL, Esenwa C. Associating cryptogenic ischemic stroke in the young with cardiovascular risk factor phenotypes. Sci Rep. 2021;11(1):275. doi:10.1038/s41598-020-79499-1