Racial differences in the utilization of therapeutic procedures in stroke patients are pervasive and contribute to worse outcomes in minorities compared to whites after stroke. Swallowing dysfunction immediately after stroke is common, but most patients recover adequate swallowing function within a few days or weeks. Percutaneous gastrostomy (PEG) tubes for enteral feeding are commonly placed for patients who are perceived unlikely to recover adequate swallowing function in a timely manner, but ideally are avoided as PEG placement is invasive, carries the risk of procedure-related complications, and has been associated with poor long-term outcomes. Clinical decision-making surrounding PEG placement lacks objective and standardized criteria, but is largely dependent on clinical swallowing evaluations by Speech-Language Pathology (SLP) providers, and use of ancillary radiographic swallow studies such as a videofluoroscopic swallow study (VFSS). The PI?s preliminary data show that PEG tubes are overutilized in minorities compared to whites despite similar stroke severity, medical comorbidities, and incidence of swallowing dysfunction. The research proposed in the current application will investigate the potential mechanisms underlying racial disparities in PEG tube placement after stroke by thoroughly addressing the various care processes involved in evaluation of swallowing recovery and decision-making regarding PEG placement.
The specific aims are (1) to investigate whether access to SLP services including frequency of bedside swallow evaluations and VFSS testing differs among black and white stroke patients, (2) to determine the presence of an unconscious (implicit) racial bias and its effect on PEG decision-making among SLP providers, and (3) to assess whether patient-SLP provider communication behavior during bedside swallow evaluations differs between race-concordant (white patient, white SLP provider), and race-discordant (black patient, white SLP provider) patient-SLP provider pairs. This project is proposed as part of a career development plan for the PI, a cerebrovascular neurologist, to obtain training in methodology related to the study of implicit bias, patient-provider communication, and advanced statistical methods. The training program and the mentoring team the PI has assembled will help to elucidate important mechanisms underlying racial disparities in PEG placement after stroke, position him to apply the newly acquired skill set to investigate implicit bias and patient-provider communication behavior as the underlying mechanisms of other disparities in stroke care, and allow him to develop strategies aimed at mitigating disparities in stroke care via future interventional studies as he transitions to become an independent clinical investigator.

Public Health Relevance

Racial differences in the utilization of inpatient procedures, such as gastrostomy tubes, are common after stroke, and contribute to worse health outcomes among minorities compared to whites. The aim of this study is to understand the mechanisms underlying overutilization of gastrostomy tubes in black compared to white stroke patients, specifically to elucidate the role of differential access to Speech-Language Pathology (SLP) care, implications of implicit race bias among SLP providers, and patient-provider communication behavior. This knowledge will be critical in order to develop effective interventions aimed at mitigating racial disparities in stroke delivery of care.

Agency
National Institute of Health (NIH)
Institute
National Institute of Neurological Disorders and Stroke (NINDS)
Type
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
5K23NS101124-03
Application #
9670170
Study Section
Neurological Sciences Training Initial Review Group (NST)
Program Officer
Janis, Scott
Project Start
2017-04-15
Project End
2021-03-31
Budget Start
2019-04-01
Budget End
2020-03-31
Support Year
3
Fiscal Year
2019
Total Cost
Indirect Cost
Name
Johns Hopkins University
Department
Neurology
Type
Schools of Medicine
DUNS #
001910777
City
Baltimore
State
MD
Country
United States
Zip Code
21205
Faigle, Roland; Cooper, Lisa A; Gottesman, Rebecca F (2018) Race Differences in Gastrostomy Tube Placement After Stroke in Majority-White, Minority-Serving, and Racially Integrated US Hospitals. Dysphagia 33:636-644
Bongiorno, Diana M; Daumit, Gail L; Gottesman, Rebecca F et al. (2018) Comorbid Psychiatric Disease Is Associated With Lower Rates of Thrombolysis in Ischemic Stroke. Stroke 49:738-740
Faigle, Roland; Carrese, Joseph A; Cooper, Lisa A et al. (2018) Minority race and male sex as risk factors for non-beneficial gastrostomy tube placements after stroke. PLoS One 13:e0191293
Garg, Ravi; Prabhakaran, Shyam; Holl, Jane L et al. (2018) Improving the Accuracy of Scores to Predict Gastrostomy after Intracerebral Hemorrhage with Machine Learning. J Stroke Cerebrovasc Dis 27:3570-3574
Faigle, Roland; Ziai, Wendy C; Urrutia, Victor C et al. (2017) Racial Differences in Palliative Care Use After Stroke in Majority-White, Minority-Serving, and Racially Integrated U.S. Hospitals. Crit Care Med 45:2046-2054
Faigle, Roland; Urrutia, Victor C; Cooper, Lisa A et al. (2016) Racial Differences in Utilization of Life-Sustaining vs Curative Inpatient Procedures After Stroke. JAMA Neurol 73:1151-3