Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021.



Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke.


To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups.

Design, setting, and participants

This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023.


TS phases I (2010-2013), II (2014-2018), and III (2019-2021).

Main outcomes and measures

The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes.


Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours.

Conclusions and relevance

In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.





Published Version (Please cite this version)


Publication Info

Man, Shumei, Nicole Solomon, Brian Mac Grory, Brooke Alhanti, Jeffrey L Saver, Eric E Smith, Ying Xian, Deepak L Bhatt, et al. (2024). Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021. JAMA network open, 7(2). p. e2352927. 10.1001/jamanetworkopen.2023.52927 Retrieved from

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Nicole Solomon

Biostatistician, Senior
Mac Grory

Brian C. Mac Grory

Associate Professor of Neurology

Dr. Brian Mac Grory, MB BCh BAO, MHSc, MRCP, FAHA, FANA is an Associate Professor of Neurology & Ophthalmology at the Duke University School of Medicine and a Staff Neurologist at Duke University Medical Center. He received his medical degree from University College Dublin in Dublin, Ireland in 2011. After an internship at St. Vincent's University Hospital, Dublin, he completed a neurology residency and vascular neurology fellowship at the Yale School of Medicine/Yale-New Haven Hospital in New Haven, Connecticut. Upon completion of his training, he served for 3 years on the faculty of Brown University/Rhode Island Hospital before being recruited to Duke University in 2020.

His clinical practice encompasses both vascular and general neurology in the emergency, inpatient, outpatient, and telemedicine settings. He has a particular clinical interest in central retinal artery occlusion (CRAO or "eye stroke") and has developed a center of excellence for the treatment of this condition at Duke. He led the development of the first ever American Heart Association (AHA) scientific consensus statement on the management of CRAO which was endorsed by six professional medical societies in the United States representing neurology, neurosurgery, cardiology, ophthalmology, neuro-ophthalmology, and optometry.

Dr. Mac Grory has published over 100 peer-reviewed scientific articles appearing in JAMABritish Medical Journal, Circulation, StrokeAnnals of Neurology, JAMA Neurology, and Neurology. His research on retinal vascular disease is funded by the National Institutes of Health/National Heart, Lung, and Blood Institute (K23 HL161426), the AHA (23MRFSCD1077188), and the Duke Office of Physician-Scientist Development (FRCS #2835124). Additionally, he serves as Clinical Lead for the Get With The Guidelines-Stroke Data Analytic Program at the Duke Clinical Research Institute (DCRI) and Associate Program Director for the vascular neurology fellowship program at Duke. His research has been recognized with the Stroke Progress and Innovation Award, Stroke Care in Emergency Medicine Award, and Early Career Investigator Award from the AHA/American Stroke Association. He is a member of the AHA's Stroke Systems of Care Advisory Group, the Stroke Emergency Neurovascular Care Committee, and the Royal College of Physicians of the United Kingdom (MRCP(UK)). 

Brooke Alhanti

Statistical Scientist

Ying Xian

Adjunct Associate Professor in the Department of Neurology

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