Survival May Not Predict Quality of Care, Researchers Say
By Salynn Boyles
WebMD Health News
Reviewed by Laura J. Martin, MD
Latest Neurology News
Jan. 31, 2011 -- New research suggests that African-Americans have a better survival rate than whites after hospitalization for stroke, but the study raises more questions than it answers about the impact of treatment decisions on outcomes and the meaning of stroke mortality statistics, investigators say.
Using data from a statewide hospital registry, researchers examined survival among all stroke patients treated in New York state in 2005 and 2006.
In addition to living longer, African-American patients were less likely than whites to receive clot-busting drugs but more likely to receive treatments considered to be end-of-life interventions, such as cardiopulmonary resuscitation or kidney dialysis.
They were also less likely to be discharged to hospice care following treatment.
Since the registry did not include information on stroke severity or post-stroke quality of life, it is possible that longer survival did not mean better outcomes for the patients in the study, lead author Ying Xian, MD, tells WebMD.
The study was published today in the Annals of Internal Medicine.
"Mortality is an important measure of quality of care, but it is not the only measure," he says. "A patient's neurological status, disability, and quality of life have to also be considered."
Stroke Survival Better for African-Americans
African-Americans are more likely to suffer strokes than whites, and studies suggest that they have less access to state-of-the-art stroke treatments.
It would stand to reason that their short-term survival following hospitalization for stroke would be worse, but that is not what this study and several others have found, University of Rochester neurologist Robert Holloway, MD, MPH, tells WebMD.
"Ours is not the first study to show that after admission to the hospital, survival among black and white stroke patients may differ in ways that are unexpected," he says.
Holloway, Xian, and colleagues examined outcomes over the course of a year among 5,219 African-American and 18,340 white stroke patients treated at 164 hospitals in New York state.
Among the major findings:
- The death rate during hospitalization for stroke was 5% among African-American patients and 7.4% among whites.
- The death rate one month after a stroke was 6.1% among African-American patients and 11.4% among whites.
- The death rate at one year after a stroke was 16.5% among African-American patients and 24.4% among whites.
- Whites were less likely than blacks to receive life-sustaining interventions like intubation, cardiopulmonary resuscitation, and tracheostomy.
It has been suggested that blacks have a higher incidence than whites of strokes caused by small vessel disease. These strokes tend to be less deadly than those affecting the large vessels that supply oxygen to the brain, but Holloway and Xian do not believe this fully explains the mortality difference seen in their study.
Mortality Poor Predictor of Stroke Care
While they were unable to examine the role of patient and family-member treatment decisions on outcomes, both researchers believe these decisions probably played a major role.
In a study published last year, Holloway and colleagues found that deaths occurring immediately following stroke are often due to withholding or withdrawing life-sustaining interventions.
The newly published study and others suggest that African-Americans are more likely than whites to have these life-sustaining interventions, but it is not clear if patients and family members are fully informed when they decide to have them.
In his own research, Harvard University researcher Angelo E. Volandes, MD, found that race was not an independent predictor of the use of aggressive end-of-life treatments.
He found that when patients and family members fully understood the implications of the treatment choices they were making, they were less likely to opt for aggressive life-extending treatments regardless of race.
Volandes says the fact that more whites than African-Americans in the newly published study received hospice care suggests that whites may have been more aware of different treatment options such as hospice.
Holloway says the study also illustrates the limitations of using survival as a measure of stroke care quality.
Federal policymakers are reportedly considering requiring hospitals to publish 30-day survival data on stroke patients covered by Medicare and Medicaid.
"We have to confront the possibility that the highest quality of care doesn't always mean the longest survival," he says.
SOURCES: Xian, Y. Annals of Internal Medicine, Jan. 31, 2011; vol 154: pp 152-159.Ying Xian, MD, PhD, research fellow, Duke Clinical Research Institute, Duke University Medical Center, Durham, N.C.Robert Holloway, MD, MPH, neurologist, University of Rochester Medical Center, Rochester School of Medicine and Dentistry, Rochester, N.Y.Angelo E. Volandes, MD, assistant professor of internal medicine, Harvard Medical School and Massachusetts General Hospital, Boston.Volandes, A.E. Journal of Palliative Medicine, June 2008.
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