NeuroVoices: Ralph Sacco, MD, MS, on Improving Disparities and Expanding Research in Stroke Care


The chair of neurology and Olemberg Family Chair of Neurological Disorders at the University of Miami Miller School of Medicine discussed solutions to improve disparities in stroke care and the need for future research on social determinants of health.

Ralph Sacco, MD, MS, FAAN, FAHA

Ralph Sacco, MD, MS, FAAN, FAHA

This is a 2-part interview. To view part 1, click here.

At the American Stroke Association’s (ASA) International Stroke Conference 2021, March 17–19, a number of abstracts highlighted the inequalities in stroke care across different racial and ethnic groups, as well as the reasons behind why these inequalities exist. In 1 study, researchers found significant race-ethnic and geographical disparities in the delivery of endovascular therapy, calling for the need to improve access for all eligible patients with stroke.1

Another abstract included findings from the Transitions of Care Stroke Disparities Study, which rooted similar issues and explored how social determinants of health can play a role in stroke incidence and disparities in care.2 Researchers concluded that mechanisms by which education, economic conditions, and psychosocial factors all may influence these outcomes, but that additional research is needed.

Stroke expert Ralph Sacco, MD, MS, FAHA, FAAN, was a part of each of these studies and claims that it’s time to start turning statistics into action. Sacco, chair of neurology and Olemberg Family Chair of Neurological Disorders at the University of Miami Miller School of Medicine, sat down as part of our NeuroVoices series to provide perspective on what communities can begin to do to improve these disparities.

NeurologyLive: How can we start to improve the disparities within different racial groups? Who needs to come to the table for this change to come about?

Ralph Sacco, MD, MS, FAHA, FAAN: A lot of our mantra is to turn these measurements into action. We always remind both the public and our physicians that before you can make a change, you have to know there’s a problem. Much of our data first begins to show a disparity and then we try to delve into what is driving that disparity and how can we correct it.

Some of those things are educational campaigns. We need to get the word out still, particularly in underserved populations, about calling 9-1-1 and getting urgent attention for stroke. We need to continue to emphasize that.

High blood pressure is the “silent killer,” and many people don’t know their blood pressure is elevated. Getting more access to individuals to have their blood pressure checked and then being able to know their numbers and get them on the right medications is important. A lot of what the American Heart Association focuses on is understanding about lifestyle modification. We focus on weight reduction, physical activity, not smoking, dieting. All of that to help reduce the risk of stroke.

The other thing that we’ve worked on in the Florida Stroke Registry was to educate our systems and learn from each other. Some people can give TPA and endovascular therapy very rapidly and they have all the systems set up to do that. In the early phases of our Florida Stroke Registry, we created these modules where we instructed people about giving TPA in the CT scanner, having the TPA ready to go, calling when the EMS person gets there, having the EMS person call the emergency room personnel to let them know a stroke patient is coming. All of these things are done to try to reduce delays in care.

Working with EMS, there have been transport policies that have been established. EMS has a big program now where they’re trying to get dispatchers to be better trained in recognizing stroke with certain symptoms over the phone so they can dispatch appropriately and get them quickly to an acute stroke hospital. A lot of it is educational awareness, giving people the right tools to more rapidly recognize and treat acute stroke.

A big area of focus for us right now is transitions of care. People come into the hospital, they receive this great care, but we’re worried that when they leave the hospital, there is a gap in care. When they go back to the community, is everything communicated? Do they remain taking their medicines? Is your blood pressure well controlled? Do they take anti-platelets as needed? There’s this concern that there’s not a good transition of care, and therefore, there’ll be a higher risk of recurrent stroke, or possibly a readmission for complications from stroke. We’re beginning to focus a lot more on models, systems, and interventions to improve the transition of care.

Why has there been limited research on the relationship of social determinants of health on severity and disability? What advantages does this type of research bring to the stroke community?

There has been an interest in social determinants of health. The problem sometimes is collecting the data. For example, in our Florida Stroke Registry, we don’t have a lot of social determinants of health collected. We didn’t even have education or occupation. We have their zip code, but we don’t have their full address. There’s certain things that are not well coded in acute stroke registries for social determinants of health. This analysis used their zip code and then we worked with a company to give us other social determinants of health. How many parks, how much access to fruits and vegetables, socioeconomic status based on income in the area, crime status, access to physical activities and gyms. These are all environmental determinants that describe the community in which you live in.

We wanted to connect that with the actual acute stroke performance and then the transitions of care. Why is that important? It’s not just about changing your blood pressure medication or taking an aspirin. There are other things that we have to be advocates for. We can tell everybody about the right diet, but if they can’t get to the right places to buy the right food, that’s an issue. Access to healthy food delivery areas are important. We can tell people to exercise but if I live in an urban area where there are no safe places to walk or a park, that’s a problem.

These are important findings, but we then have to advocate to government and other non-government entities about policies to improve access to healthy food, make fruits and vegetables more affordable for people who can’t afford them, make sure parks or facilities for physical activity are opened for others to utilize. Other ways to rethink in a different way to provide access to some of these other environmental determinants that we lose sight of that are important for determining stroke risk as well as stroke outcomes.

Did you have any takeaways from any specific data presented at ISC 2021 regarding COVID-19 and stroke?

There have been many presentations about COVID throughout the year that have been published and we’re still learning quite a bit about the virus in stroke. Early on, we saw in the Florida Stroke Registry and in other places that the number of people coming in with stroke was dropping and we were worried that people were having symptoms and staying home. That’s 1 perception. It’s not clear why the amount of stroke cases dropped off.

We quickly educated all of our hospitals on how to provide acute stroke care, using PPE, and all the precautions someone must take regarding COVID-19. Our stroke centers came up to speed quickly to continue to provide acute care. Then working with the American Heart Association, we tried to tell the public to not delay, don’t be fearful to call 9-1-1.

There was also a lot of concern about young people with stroke and COVID-19 hypercoagulability. It is shown that patients with severe cases of COVID-19 have this market inflammatory and thrombotic storm that could occur with the inflammation that their body responds to with the virus. There was some concern back and forth. It’s still not clear whether stroke is increased or not. Some say it is, some say it’s not clear. Obviously, if you have severe COVID-19, the risk of major complications, including thrombotic and clotting complications which include stroke, go up. But it’s not severely increased like we originally thought in the beginning.

The other interesting area that we’re still learning about is post-acute COVID. Some of that may be more cognitive, not necessarily stroke, but there’s this concern of brain fog and other neurological sequelae. Numerous people are beginning to look at that. Will people who survive COVID have increased risk of stroke? Will they have increased risk of cognitive decline? There’s still a lot more that we need to understand about COVID-19 and those who had been infected, even the mild infections, and what their repercussions are. That’s what’s being looked at. Right now, the good thing is that obviously more people are getting vaccinated, and the cases are going down. We didn’t see, which we were worried about, a huge surge in strokes with COVID-19.

Transcript edited for clarity.

1. Wang K, Gutierrez CM, Mueller NH, et al. Disparities in delivery of endovascular therapy: data from the Florida Stroke Registry. Presented at International Stroke Conference; March 17–19. Abstract P875
2. Gardener H, Wang K, Rodriguez A, et al. A multi-level exploration of the social determinants of health in Florida: initial findings from the Transitions of Care Stroke Disparities study. Presented at International Stroke Conference; March 17–19. Abstract P882
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