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Structural discrimination may reduce access to certified stroke center care for Black Americans, an observational study suggested.

Black, racially segregated communities had the highest likelihood of hospitals with certified stroke care (HR 1.67, 95% CI 1.41-1.97) in models not accounting for population size, reported Renee Hsia, MD, MSc, of University of California San Francisco, and co-authors, in .

However, after adjusting for population and hospital size, patients in these communities were 26% less likely to have access to care at a certified stroke center (HR 0.74, 95% CI 0.62-0.89), Hsia and colleagues wrote.

Other historically underserved communities also had less access to certified stroke care. Hospitals in low-income areas had a lower likelihood of hospitals with a stroke center than high-income areas, and rural hospitals were much less likely to adopt stroke care certification than urban hospitals (HR 0.43, 95% CI 0.35-0.51).

For their study, Hsia and co-authors focused on structural discrimination -- inequitable systems not intentionally designed to be.

"People tend to think about racism on an individual level, but in our healthcare system, it can be quite insidious and not evident on the surface," Hsia told MedPage Today.

Yet, because of significant market forces, "hospitals, as well as services within existing hospitals, tend to pop up generally where there's a higher proportion of people who are privately insured, in wealthier zip codes, and in richer hospitals," she said.

The retrospective analysis tracked levels of stroke-care certification -- long associated with better patient outcomes -- across 4,984 acute-care U.S. hospitals from January 2009 through December 2019. In that period, the total number of hospitals with stroke certification, ranging from acute-stroke ready status to comprehensive certification for the most complex cases, grew from 964 to 1,763.

In total, 3,390 hospitals (68%) served non-Black, racially integrated communities; 486 (9.8%) served non-Black racially segregated communities; 610 (12.2%) served Black, racially integrated communities; and 498 (10%) served Black, segregated communities.

Hsia and colleagues defined the term "historically underserved" through four measures: racial and ethnic composition, income distribution, and rurality. All categories, except rural, were analyzed on the basis of composition and degree of segregation for each of the characteristics. Segregation encompassed a broad meaning which included racial, ethnic, and economic segregation, Hsia said.

"Do people who are poor and rich live within the same communities, or is there an 'unevenness' in how poor residents and rich residents are geographically distributed?" she asked. For example, do poor residents live in one part of town and wealthier residents in another, or "do they live next to each other?"

"We think these factors matter in terms of access to care and even how hospitals determine where they want to be located," she said.

In many low-income, minority, and rural communities, specialized stroke services are not even an option, despite efforts by the Joint Commission in partnership with the American Heart Association since 2004 to standardize best practices in stroke care through the certification process, Hsia pointed out. "Currently, the distribution of stroke care in the country is more motivated by profit potential, rather than community need," she said in a statement.

Certified stroke care centers are associated with lower mortality and less severe post-stroke disability, the researchers noted. Given that racial and ethnic minorities, low-income, and rural patients already face a higher baseline risk of stroke, "this disparity in access to care could be a double hit" in their communities, they wrote.

Hsia and colleagues listed a lack of a national database on stroke centers as the main limitation of the research, requiring data-gathering from individual states and various certification organizations. Despite an overlap in characteristics that defined underserved populations, the researchers estimated each one individually.

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