Racial- and Gender-Based Disparities in IV-Alteplase Declination

In this issue of Neurology®, Mendelson et al.¹ use data from the Get With The Guidelines Stroke Registry to describe race- and gender-based disparities in IV alteplase (IV tissue plasminogen activator [tPA]), specifically the rates at which there is documentation that patients with acute ischemic stroke (AIS) decline treatment with thrombolytics. Among 177,115 patients (at >1,900 hospital sites) with AIS in whom no contraindications to tPA were documented, 3.7% were reported to have declined tPA. Compared with White individuals, the odds of tPA declination for Black patients were 21% higher (95% CI 1.11–1.31), while Asian patients had 28% lower odds of tPA declination (95% CI 0.48–0.88). Women were 17% more likely than men to have tPA declination documented (95% CI 1.11–1.23) as the reason for no tPA administration. Of note, the authors' statistical model included a large number of variables, including mode of and time to arrival, insurance status, medical comorbid conditions, the geographic location of the hospital, stroke center status, and other hospital characteristics such as annual stroke volume and percent of patients treated at the hospital site who were Black. Other variables that were significantly associated with an increased likelihood of tPA declination were older age (among those >65 years of age only) and having Medicaid insurance. Factors associated with a lower likelihood of tPA declination were treatment at a teaching hospital, larger annual IV tPA volume, and longer times from onset to arrival (but only among those arriving >90 minutes after symptom onset).