Effect of Race on Rates of Patent Foramen Ovale Closure during Acute ischemic Stroke Hospitalization in the United States.

Background: Published data indicate that African American stroke patients are significantly less likely than their non-Hispanic White counterparts to receive therapeutic procedures in acute ischemic stroke (AIS). Little is known about frequency of PFO closure for secondary stroke prevention by race among patients with cryptogenic stroke. Objective: To investigate trends in PFO closure among hospitalized patients in the U.S., with an emphasis on treatment by race. Methods: The Nationwide Inpatient Sample was queried from 2006 to 2014 for all patients older than 18-years of age with a primary diagnosis of AIS who had procedure codes for PFO closure excluding congenital heart disease. We utilized multivariable logistic regression analyses to study the independent association between race and trends in PFO closure. Results: A population of patients with AIS (n=1028565), excluding congenital heart disease, was analyzed. The queried was divided by PFO closure (n=384) and no PFO closure (n=1028181). Demographic variables included age, gender (male or female) race (White, African American, Hispanic, others) and payer status (Medicare, Medicaid, private, other). In multivariable logistic regression, the odds to have a PFO closure was greatest in the 18-45 age group [age 45-65 (Odds Ratio [OR]: 0.27, 95% CI: 0.20-0.35); age 65-84 (OR: 0.11, 95% CI: 0.81-0.15); age ≥85 (OR: 0.02, 95% CI: 0.01-0.05)], no difference among genders was found (OR: 1.14, 95% CI: 0.93-1.40). African Americans were less likely have PFO closure (OR: 0.51, 95%, CI: 0.35-0.74) when compared to Whites. Private insurance (OR: 1.5, 95% CI: 1.16-2.16); urban teaching hospitals (OR: 3.0, 95% CI: 1.35-6.83); higher median household income for patient’s ZIP code (OR: 2.14, 95% CI: 1.46-3.11); higher Charlson’s Comorbidity Index (OR: 0.78, 95% CI: 0.68-0.90) and admission in 2011-2014 (OR: 0.49, 95% CI: 0.31-0.78) were found to increase the likelihood of having a percutaneous PFO closure after an AIS. Conclusions: Over the last decade in the U.S., being African American was associated with a significantly lower likelihood of receiving percutaneous PFO closure. Now that the beneficial role of PFO closure for cryptogenic stroke is established, this racial disparity needs to be monitored and bridged.