American Journal of Epidemiology

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American Journal of Epidemiology Vol. 154, No. 11 : 1057-1063
Copyright © 2001 by The Johns Hopkins University School of Hygiene and Public Health

ORIGINAL CONTRIBUTIONS

Racial/Ethnic Disparities in Mortality by Stroke Subtype in the United States, 1995–1998

Carma Ayala^1,2, Kurt J. Greenlund², Janet B. Croft², Nora L. Keenan², Ralph S. Donehoo³, Wayne H. Giles², Steven J. Kittner⁴ and James S. Marks⁵

¹ Epidemic Intelligence Service, Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA.
² Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
³ Community Health and Program Services Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
⁴ Department of Neurology and the Department of Epidemiology and Preventive Medicine, University of Maryland at Baltimore, MD, and the Geriatrics Research, Education, and Clinical Center, Baltimore Department of Veterans Affairs Medical Center, Baltimore, MD.
⁵ Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

	ABSTRACT

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Healthy People 2010 objectives for improving health include a goal to eliminate racial disparities in stroke mortality. Age-specific death rates by stroke subtype are not well documented among racial/ethnic minority populations in the United States. This report examines mortality rates by race/ethnicity for three stroke subtypes during 1995–1998. National Vital Statistics' death certificate data were used to calculate death rates for ischemic stroke (n = 507,256), intracerebral hemorrhage (n = 97,709), and subarachnoid hemorrhage (n = 27,334) among Hispanics, Blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Whites by age and sex. Comparisons with Whites as the referent were made using age-standardized risk ratios and age-specific risk ratios. Age-standardized mortality rates for the three stroke subtypes were higher among Blacks than Whites. Death rates from intracerebral hemorrhage were also higher among Asians/Pacific Islanders than Whites. All minority populations had higher death rates from subarachnoid hemorrhage than did Whites. Among adults aged 25–44 years, Blacks and American Indians/Alaska Natives had higher risk ratios than did Whites for all three stroke subtypes. Increased public health attention is needed to reduce incidence and mortality for stroke, the third leading cause of death. Particular attention should be given to increasing awareness of stroke symptoms among young minority groups.

Asian Americans; Blacks; cerebral hemorrhage; cerebrovascular accident; Hispanic Americans; Indians, North American; mortality; subarachnoid hemorrhage

Abbreviations: CI, confidence interval; ICD-9, International Classification of Diseases, Ninth Revision

	INTRODUCTION

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Although stroke is the third leading cause of death in the United States (1) and its overall mortality rates are well documented, few studies have addressed racial/ethnic differences in stroke mortality (2–4). In 1997, all racial/ethnic minority populations aged 35–64 years experienced higher mortality rates for stroke than did the White population (5). Currently, more than 25 percent of the US population is composed of racial/ethnic minority populations and, by 2050, that percentage should nearly double (6). Thus, there is an increasing need to understand racial/ethnic differences in stroke mortality so that appropriate public health interventions might be developed to eliminate disparities.

In addition, racial/ethnic stroke mortality differentials may exist according to the type of stroke. Ischemic stroke accounts for 70–80 percent of all strokes, but cerebral and subarachnoid hemorrhagic stroke have higher risks of fatality (7). Examining the patterns of stroke subtypes among racial/ethnic populations could help target prevention efforts. In this report, we present national, racial/ethnic, age- standardized, and age-specific mortality rates and risk ratios for stroke subtypes among the major racial/ethnic groups: non-Hispanic American Indians/Alaska Natives, non-Hispanic Asians/Pacific Islanders, non-Hispanic Blacks, non-Hispanic Whites, and Hispanics.

	MATERIALS AND METHODS

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National Vital Statistics' data for death certificates were used to determine death rates and risk ratios for stroke mortality among persons who were 25 years during 1995–1998. In addition to medical examiners and coroners, practicing physicians report the cause of death on the certificates. The death certificates are processed in state vital statistics offices and then sent to the National Center for Health Statistics at the Centers for Disease Control and Prevention for entry into a national detailed mortality database file (1). Death rates exclude nonresidents. For this study, observed stroke deaths were those for which the underlying cause of death was classified according to the International Classification of Diseases, Ninth Revision (ICD-9), codes 430–438 as listed on death certificates. Stroke subtypes were defined as subarachnoid hemorrhage (code 430), intracerebral hemorrhage (codes 431–432), and ischemic stroke (codes 433–434 or 436–438). Deaths attribbuted to transient ischemic attack (code 435) were excluded, but these events accounted for <1 percent of stroke deaths. There were no deaths listed as ICD-9 code 432 (other or unspecified intracerebral hemorrhage) during this time period. Demographic information, such as age, race, and ethnicity, is reported on death certificates by funeral directors on the basis of observation or information with which they are provided, usually by family members. Since 1992, information on both race and Hispanic origin has been requested on death certificates.

Death rates and risk ratios were calculated for groups defined by race/ethnicity, sex, and age (25–44, 45–64, and > = 65 years). Mortality rates (per 100,000 population) for the 4-year period 1995–1998 were calculated as the number of deaths divided by the population of interest. Population data (denominators for death rates) were postcensal estimates from the US Bureau of the Census. Age-standardized death rates were calculated by the direct method using the year 2000 standard US population (8). To estimate the overall excess risk for stroke death among racial/ethnic minority populations, we calculated risk ratios and 95 percent confidence intervals by dividing the rate for each racial/ethnic group by the rate for the White population (9). To estimate the excess risk in age groups, the risk ratios and 95 percent confidence intervals were calculated by dividing the mortality rates in each age group by the corresponding White mortality rates (10). Risk ratios of 1.0 indicate higher death rates or excess risk for the minority population than for Whites, while ratios of <1.0 indicate a lower rate or risk. Risk ratios are not presented for a category with 20 deaths because of potential instability of the estimate. Because the number of deaths in a given year was quite small in some subgroups, data were combined for 1995–1998 to create more robust estimates.

	RESULTS

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In 1995–1998, there were 507,256 deaths from ischemic stroke, 97,709 from intracerebral hemorrhage, and 27,334 from subarachnoid hemorrhage among adults aged 25 years. Ischemic strokes accounted for 80 percent of deaths from these stroke subtypes (82 percent among non-Hispanic Whites, 75 percent among non-Hispanic Blacks, 74 percent among non-Hispanic American Indians/Alaska Natives, 62 percent among non-Hispanic Asians/Pacific Islanders, and 67 percent among Hispanics). For ischemic stroke, the age-standardized death rate among Blacks (95.8 per 100,000) was 1.30 (95 percent confidence interval (CI): 1.29, 1.31) times or 30 percent higher than the rate for Whites (73.7 per 100,000), while American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic adults had lower death rates than Whites (table 1). For intracerebral hemorrhage, death rates for Blacks and Asians/Pacific Islanders were 1.70 (95 percent CI: 1.67, 1.74) and 1.52 (95 percent CI: 1.47, 1.58) times, respectively, as high as those of Whites. All minority populations had higher rates for subarachnoid hemorrhage than did Whites. Similar racial/ethnic differences were observed among both men and women (figure 1). Black men and women had the highest death rates for all three stroke subtypes, while Asian/Pacific Islander men and women also had high rates for both intra-cerebral and subarachnoid hemorrhagic stroke.

View this table: [in this window] [in a new window]   TABLE 1. Age-standardized death rates (per 100,000 population) from stroke subtypes and risk ratios* and 95% confidence intervals comparing rates in racial/ethnic populations with those in White populations among adults aged 25 years or older, United States, 1995–1998

 

View larger version (25K): [in this window] [in a new window]   FIGURE 1. Age-standardized death rates (per 100,000 population) for stroke subtype among adults aged 25 years or older, by race/ethnicity and sex, United States, 1995–1998. Death rates per 100,000, age adjusted to the 2000 total US standard population. International Classification of Diseases, Ninth Revision, codes for subarachnoid hemorrhage (code 430), intracerebral hemorrhage (codes 431–432), and ischemic hemorrhage (codes 433, 434, 436–438). Transient cerebral ischemia (code 435) was excluded. Categories for race and Hispanic origin (racial/ethnic populations) are mutually exclusive: NH, non-Hispanic; AIAN, American Indian/Alaska Native; API, Asian/Pacific Islander.

 
Eighty-nine percent of ischemic stroke deaths were attributed to acute, ill-defined, cerebrovascular disease (ICD-9 code 436), other and ill-defined cerebrovascular disease (ICD-9 codes 437–437.9), and late effects cerebrovascular disease (ICD-9 code 438) (figure 2). Only 5 percent of ischemic stroke deaths were classified as other (code 437.8) or unspecified (code 437.9). There were no appreciable differences among the racial/ethnic groups in the percentage distribution of these ICD-9 ischemic stroke classifications. When the analysis was repeated excluding these codes, there was essentially no change in the risk ratios.

View larger version (30K): [in this window] [in a new window]   FIGURE 2. Percentage of ischemic stroke deaths in adults aged 25 years or older by International Classification of Diseases, Ninth Revision (ICD-9), codes for ischemic stroke (codes 433–434.9, 436–438) and race/ethnicity, United States, 1995–1998. Categories for race and Hispanic origin (racial/ethnic populations) are mutually exclusive: NH, non-Hispanic; AIAN, American Indian/Alaska Native; API, Asian/Pacific Islander.

 
As expected, the death rates for all three stroke subtypes increased with age among all racial/ethnic populations (table 2). For all three stroke subtypes, Blacks and American Indians/Alaska Natives at younger ages had higher rates of death than did Whites at similar ages; however, the risk of death was similar or lower at older ages. For example, the age-specific rate of intracerebral hemorrhagic deaths among Blacks was 5.20 (95 percent CI: 4.91, 5.51) times greater at ages 25–44 years, 3.94 (95 percent CI: 3.82, 4.07) times greater at ages 45–64 years, but similar (risk ratio = 1.04, 95 percent CI: 1.01, 1.07) at ages 65 years compared with the death rate in the corresponding age group of Whites. For intracerebral hemorrhage, the risk of death was higher at younger ages among Hispanics compared with Whites and higher at all age groups for Asians/Pacific Islanders than Whites. For subarachnoid hemorrhage, Asians/Pacific Islanders had a lower risk of mortality at younger ages but a greater risk at older ages compared with corresponding Whites. The age-specific racial/ethnic differential in each minority population was similar for men and women (data not shown). Both Black men and Black women in the youngest age group, 25–44 years, had substantially higher death rates for all stroke subtypes than corresponding White men and White women.

View this table: [in this window] [in a new window]   TABLE 2. Age-specific death rates (per 100,000 population) from stroke subtypes and risk ratios* and 95% confidence intervals comparing death rates in racial/ethnic populations with death rates in the White population, adults aged 25 years or older, United States, 1995–1998

 

	DISCUSSION

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The Healthy People 2010 objectives include a goal to eliminate racial disparities in stroke mortality (11). Death rates for stroke declined by 70 percent overall from 1950 to 1996, but the rate of decline varied by race/ethnicity and halted in the early 1990s before declining again in 1995 (12). Even if death rates continue to fall, however, the aging of the population could mean that the absolute number of deaths will increase. This report and an earlier one (5) suggest an excess risk of dying from stroke at younger ages for minority groups compared with Whites.

Consistent with previous findings (7, 13–19), Black adults were more likely than their White peers to die from ischemic, intracerebral, and subarachnoid hemorrhagic stroke in 1995–1998. Previous reports suggest that racial/ethnic disparities in stroke subtype mortality may be driven by differences in incidence with more new cases occurring among Blacks and Hispanics (7, 20, 21). Community studies in the past 20 years have observed higher incidences of all three stroke subtypes among Black adults (14, 15, 17). Differences in death rates for stroke subtype between minority populations and Whites may reflect socioeconomic status, greater severity of disease and poor survival at younger ages, and variations in risk factors such as obesity, uncontrolled high blood pressure, inactivity, poor nutrition, diabetes, and cigarette smoking (2, 3, 16, 19, 22, 23). Other factors that influence death rates include the lack of access to medical care, which may include lack of health insurance, differential access to or acceptance of invasive procedures, transportation difficulties, and lack of knowledge about early warning signs of stroke (3, 16, 19–26). Deaths from stroke can be delayed or reduced by preventing and controlling these risk factors and by removing barriers to early and effective treatment. Additional targeting of these efforts in minority populations may be needed.

In the present report, we observed that a greater risk of deaths from all stroke subtypes relative to Whites was concentrated below age 65 years for both Blacks and American Indians/Alaska Natives. This pattern of a greater risk of stroke deaths at younger ages was also observed for Hispanics and Asians/Pacific Islanders for death from intracerebral hemorrhage. These racial/ethnic differences among younger adults may in part be explained by racial/ethnic differences in risk factors, especially among younger adults. The Behavioral Risk Factor Surveillance System reported for 1996–1998 that young racial/ethnic minority groups throughout the United States had a higher prevalence of smoking, obesity, and diabetes than did young Whites (24–26), which could lead to our finding of greater racial gaps among Blacks and American Indians/Alaska Natives, aged 25–44 years. A 1993 study in Cincinnati. Ohio, suggested that excess risk of subarachnoid hemorrhage in Blacks could be attributable to their more prevalent risk factors such as hypertension, smoking, alcohol abuse, and unrecognized genetic/environmental factors (15, 17). Furthermore, an earlier onset of obesity, diabetes mellitus, and hypertension in these populations (24–26) may contribute to earlier cerebrovascular vessel damage. In terms of reducing the number of people at risk for the development of intracerebral hemorrhage and ischemic stroke, these findings highlight the importance of both primary and secondary prevention for eliminating racial disparities in the development and management of hypertension, diabetes mellitus, and obesity.

Both intracerebral hemorrhage and subarachnoid hemorrhage account for over half of early age stroke deaths in population-based studies of stroke mortality (13–15). Hemorrhagic strokes are more lethal than ischemic strokes. For example, Medicare patients hospitalized for hemorrhagic stroke were five times more likely to die than those hospitalized with ischemic stroke even after adjustment for age, sex, race, hypertension, diabetes, coronary heart disease, heart failure, atrial fibrillation, stroke types, and length of hospital stay (27). In a national study of Medicare beneficiaries, the racial gap between Blacks and Whites widened from 1990 to 1995 for mortality from hemorrhagic stroke, while the gap for ischemic stroke narrowed (16). Ongoing research on other risk factors is assessing the impact of oral contraceptives, alcohol consumption, antiphospholipid antibodies, increased homocysteine, inflammation, and infection on stroke (28, 29). Eventually, these factors may be found important in explaining disparities in stroke incidence.

The aging of the US population in general suggests that the actual numbers of stroke cases could increase. Minority groups could further experience an increasing burden of stroke. The Bureau of Census estimates that Hispanic and Asian/Pacific Islander populations aged 25 years or older will increase almost 400 percent each from 1995 to 2050, while the American Indian/Alaska Native adult population will increase to 142 percent (6). The Black population is estimated to increase 116 percent by 2050, whereas the White adult population will have the smallest increases (6). Thus, public health programs for the prevention of stroke should place more focus among racial/ethnic minority populations to further reduce overall stroke mortality.

Few studies have examined stroke deaths in American Indians/Alaska Natives and in Asians/Pacific Islanders because their population sizes are small. American Indians/Alaska Natives have a greater prevalence of smoking and obesity, which may result in a higher prevalence of hypertension and diabetes mellitus (24), both of which are stroke risk factors. In our study, American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic groups had a higher mortality at younger ages for some stroke subtypes compared with Whites. Underreporting of American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic origin on death certificates and census population counts can lead to underestimates of the risk of stroke deaths in these groups (6, 30, 31). A report from the National Center for Health Statistics suggests that racial/ethnic reporting biases due to miscoding on death certificates and undercoverage in the census could result in death rates being underreported by as much as 21 percent for American Indians/Alaska Natives, 11 percent for Asians/Pacific Islanders, and 2 percent for Hispanics, as well as slightly overreporting for Blacks (5 percent) (30). Hence, we may have underestimated the racial disparity gaps for American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics and may have overestimated the gap for Blacks. There is little reported information about age misclassification on death certificates and in the census. Despite these potential limitations, our results emphasize the need to direct prevention efforts to the most vulnerable groups at risk of stroke mortality, especially among the younger aged minority populations.

Another potential limitation of this study is the accuracy of reporting cause of death using the ICD-9 codes. Historically, during the 1970s and 1980s, the classification of stroke subtypes was not considered very accurate (32). Since the advent of widespread use of computerized tomography, a death certificate diagnosis of intracranial hemorrhage versus nonhemorrhagic stroke appears to be sufficiently accurate for use in epidemiologic studies (33). Nonetheless, our findings suggest that there was no racial/ethnic difference in ICD-9-defined classifications within the stroke subtypes.

Since the 1960s, it is evident that considerable geographic variations in stroke incidence and stroke mortality exist with the highest rates observed in the stroke belt of the southeastern United States (34, 35). The patterns of age-specific excess risk of overall stroke death in the stroke belt differed between Black and White men and women (36). It is beyond the scope of the current paper to examine geographic variations for stroke subtypes between racial/ethnic groups.

Our results suggest the need for greater public health attention to the nation's third leading cause of death and highlight the need for reducing racial/ethnic disparities in stroke mortality, particularly at younger ages. Educating the public about the signs and symptoms of a stroke may be key to preventing premature stroke death among young adults who perceive stroke as a disease of the elderly. Further epidemiologic studies may help to reveal risk factor clustering that operates more specifically for stroke subtypes in those at highest risk in these populations. Targeted research and evaluation among these high-risk populations may also help to identify specific differences between and within subpopulations related to lower socioeconomic or educational levels or to adverse environmental factors.

	NOTES

 
Correspondence to Dr. Carma Ayala, Cardiovascular Health Branch, National Center for Chronic Disease Prevention and Health Promotion, Mailstop K-47, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341-3717 (e-mail: cia1{at}cdc.gov).

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Received for publication March 23, 2001. Accepted for publication August 20, 2001.

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