Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

doi:10.1161/STROKEAHA.115.012631

. 2016 Jul;47(7):1893-8.

doi: 10.1161/STROKEAHA.115.012631. Epub 2016 Jun 2.

Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

Affiliations

¹ From the Departments of Biostatistics (G.H., S.E.J.) and Epidemiology (V.J.H.), University of Alabama at Birmingham School of Public Health; Office of Clinical Research, NINDS/NIH, Bethesda, MD (C.S.M.); Department of Epidemiology and Biostatistics, Dornsife School of Public Health at Drexel University, Philadelphia, PA (L.A.M.); Department of Neurology, University of Cincinnati, OH (D.O.K., B.M.K., M.L.F.); Department of Psychology, Indiana University, Indianapolis (F.W.U.); Department of Epidemiology, Wake Forest University School of Medicine, Winston-Salem, NC (E.Z.S.); Department of General Internal Medicine, Weill Cornell School of Medicine, New York, NY (M.M.S., V.G.W.); and Department of Medicine, University of Vermont School of Medicine, Burlington (M.C.). ghoward@uab.edu.
² From the Departments of Biostatistics (G.H., S.E.J.) and Epidemiology (V.J.H.), University of Alabama at Birmingham School of Public Health; Office of Clinical Research, NINDS/NIH, Bethesda, MD (C.S.M.); Department of Epidemiology and Biostatistics, Dornsife School of Public Health at Drexel University, Philadelphia, PA (L.A.M.); Department of Neurology, University of Cincinnati, OH (D.O.K., B.M.K., M.L.F.); Department of Psychology, Indiana University, Indianapolis (F.W.U.); Department of Epidemiology, Wake Forest University School of Medicine, Winston-Salem, NC (E.Z.S.); Department of General Internal Medicine, Weill Cornell School of Medicine, New York, NY (M.M.S., V.G.W.); and Department of Medicine, University of Vermont School of Medicine, Burlington (M.C.).

PMID: 27256672
PMCID: PMC4927373
DOI: 10.1161/STROKEAHA.115.012631

Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

George Howard et al. Stroke. 2016 Jul.

. 2016 Jul;47(7):1893-8.

doi: 10.1161/STROKEAHA.115.012631. Epub 2016 Jun 2.

Affiliations

¹ From the Departments of Biostatistics (G.H., S.E.J.) and Epidemiology (V.J.H.), University of Alabama at Birmingham School of Public Health; Office of Clinical Research, NINDS/NIH, Bethesda, MD (C.S.M.); Department of Epidemiology and Biostatistics, Dornsife School of Public Health at Drexel University, Philadelphia, PA (L.A.M.); Department of Neurology, University of Cincinnati, OH (D.O.K., B.M.K., M.L.F.); Department of Psychology, Indiana University, Indianapolis (F.W.U.); Department of Epidemiology, Wake Forest University School of Medicine, Winston-Salem, NC (E.Z.S.); Department of General Internal Medicine, Weill Cornell School of Medicine, New York, NY (M.M.S., V.G.W.); and Department of Medicine, University of Vermont School of Medicine, Burlington (M.C.). ghoward@uab.edu.
² From the Departments of Biostatistics (G.H., S.E.J.) and Epidemiology (V.J.H.), University of Alabama at Birmingham School of Public Health; Office of Clinical Research, NINDS/NIH, Bethesda, MD (C.S.M.); Department of Epidemiology and Biostatistics, Dornsife School of Public Health at Drexel University, Philadelphia, PA (L.A.M.); Department of Neurology, University of Cincinnati, OH (D.O.K., B.M.K., M.L.F.); Department of Psychology, Indiana University, Indianapolis (F.W.U.); Department of Epidemiology, Wake Forest University School of Medicine, Winston-Salem, NC (E.Z.S.); Department of General Internal Medicine, Weill Cornell School of Medicine, New York, NY (M.M.S., V.G.W.); and Department of Medicine, University of Vermont School of Medicine, Burlington (M.C.).

PMID: 27256672
PMCID: PMC4927373
DOI: 10.1161/STROKEAHA.115.012631

Abstract

Background and purpose: At age 45 years, blacks have a stroke mortality ≈3× greater than their white counterparts, with a declining disparity at older ages. We assess whether this black-white disparity in stroke mortality is attributable to a black-white disparity in stroke incidence versus a disparity in case fatality.

Methods: We first assess if black-white differences in stroke mortality within 29 681 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort reflect national black-white differences in stroke mortality and then assess the degree to which black-white differences in stroke incidence or 30-day case fatality after stroke contribute to the disparities in stroke mortality.

Results: The pattern of stroke mortality within the study mirrors the national pattern, with the black-to-white hazard ratio of ≈4.0 at age 45 years decreasing to ≈1.0 at age 85 years. The pattern of black-to-white disparities in stroke incidence shows a similar pattern but no evidence of a corresponding disparity in stroke case fatality.

Conclusions: These findings show that the black-white differences in stroke mortality are largely driven by differences in stroke incidence, with case fatality playing at most a minor role. Therefore, to reduce the black-white disparity in stroke mortality, interventions need to focus on prevention of stroke in blacks.

Keywords: blacks; continental population groups; incidence; mortality; stroke.

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Figures

**Figure 1**
Age-specific (for age 45 and over) Black-to-White mortality ratio for deaths from cerebrovascular diseases (ICD-10: 160 – 169) in the United States for years 2003 to 2007 (inclusive). Note that both the number of people dying of stroke, and the number of people in the population, are from a census (Census of the population and U.S. Vital Statistics) and include all people in the US. As such, there is no sampling variation of the estimated age-specific mortality rates underlying the mortality ratio, and hence no sampling variation (and hence no confidence bounds) on the mortality ratios.

**Figure 2**
A and B: Black-to-White hazard ratio (with 95% confidence limits) for fatal stroke (mortality analysis) after adjustment for sex. Figure 1A provides the hazard ratio from a model with age as a categorical variable, while 1B from a model with age as a continuous variable.

**Figure 3**
A and B: Black-to-White hazard ratio (with 95% confidence limits) for any stroke (incidence analysis) after adjustment for sex. Figure 2A provides the hazard ratio from a model with age as a categorical variable, while 2B from a model with age as a continuous variable.

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References

1. Wylie CM. Recent trends in mortality from cerebrovascular accidents in the united states. J Chronic Dis. 1960;14:213–220. - PubMed
1. Centers for Disease Control and Prevention, National Center for Health Statistics. (Data are from the Compressed Mortality File 1999–2014 Series 20 No. 2T, 2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program).Compressed Mortality File 1999–2014 on CDC WONDER Online Database, released December 2015. Accessed at http://wonder.cdc.gov/cmf-icd10.html on Jan 10, 2016 4:41:08 PM.
1. Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al. Factors influencing the decline in stroke mortality: A statement from the American Heart Association/American Stroke Association. Stroke. 2014;45:315–353. - PMC - PubMed
1. Howard G. Ancel keys lecture: Adventures (and misadventures) in understanding (and reducing) disparities in stroke mortality. Stroke. 2013;44:3254–3259. - PMC - PubMed
1. Kleindorfer D, Broderick J, Khoury J, Flaherty M, Woo D, Alwell K, et al. The unchanging incidence and case-fatality of stroke in the 1990s: A population-based study. Stroke. 2006;37:2473–2478. - PubMed

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[1] Wylie CM. Recent trends in mortality from cerebrovascular accidents in the united states. J Chronic Dis. 1960;14:213–220. - PubMed

[2] Wylie CM. Recent trends in mortality from cerebrovascular accidents in the united states. J Chronic Dis. 1960;14:213–220. - PubMed

[3] Centers for Disease Control and Prevention, National Center for Health Statistics. (Data are from the Compressed Mortality File 1999–2014 Series 20 No. 2T, 2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program).Compressed Mortality File 1999–2014 on CDC WONDER Online Database, released December 2015. Accessed at http://wonder.cdc.gov/cmf-icd10.html on Jan 10, 2016 4:41:08 PM.

[4] Centers for Disease Control and Prevention, National Center for Health Statistics. (Data are from the Compressed Mortality File 1999–2014 Series 20 No. 2T, 2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program).Compressed Mortality File 1999–2014 on CDC WONDER Online Database, released December 2015. Accessed at http://wonder.cdc.gov/cmf-icd10.html on Jan 10, 2016 4:41:08 PM.

[5] Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al. Factors influencing the decline in stroke mortality: A statement from the American Heart Association/American Stroke Association. Stroke. 2014;45:315–353. - PMC - PubMed

[6] Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al. Factors influencing the decline in stroke mortality: A statement from the American Heart Association/American Stroke Association. Stroke. 2014;45:315–353. - PMC - PubMed

[7] Howard G. Ancel keys lecture: Adventures (and misadventures) in understanding (and reducing) disparities in stroke mortality. Stroke. 2013;44:3254–3259. - PMC - PubMed

[8] Howard G. Ancel keys lecture: Adventures (and misadventures) in understanding (and reducing) disparities in stroke mortality. Stroke. 2013;44:3254–3259. - PMC - PubMed

[9] Kleindorfer D, Broderick J, Khoury J, Flaherty M, Woo D, Alwell K, et al. The unchanging incidence and case-fatality of stroke in the 1990s: A population-based study. Stroke. 2006;37:2473–2478. - PubMed

[10] Kleindorfer D, Broderick J, Khoury J, Flaherty M, Woo D, Alwell K, et al. The unchanging incidence and case-fatality of stroke in the 1990s: A population-based study. Stroke. 2006;37:2473–2478. - PubMed

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Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

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Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

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