All ETDs from UAB

Advisory Committee Chair

Virginia Howard

Advisory Committee Members

Vera Bittner

Justin Blackburn

George Howard

Paul Muntner

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Public Health


Due to increase in incidence and improvements in stroke mortality, the number of stroke survivors will increase over the next decade; each stroke survivor is at risk for recurrent stroke. Thus, identifying populations with the highest risk and ensuring they receive evidence-based secondary stroke prevention (SSP) is paramount. This includes ensuring access and adherence to statins. The American Heart Association (AHA)/American Stroke Association (ASA) Scientific Statement on Racial-Ethnic Disparities in Stroke Care reported that recurrent stroke risk is higher among blacks than whites and suggested that lower adherence to current standards of SSP in blacks might help explain these discrepancies. To date, studies supporting the higher recurrent stroke in blacks are limited and have produced conflicting results. Furthermore, adherence to statins, an important component of the recommended SSP regimen, has not been extensively studied among individuals hospitalized for ischemic stroke. The goal of this dissertation was to determine if black-white differences exist in recurrent ischemic stroke, statin adherence following ischemic stroke, and discharge statin prescribing. Using a 5% Medicare sample from the Centers for Medicare and Medicaid Services (CMS; 1999- 2013), we observed that compared to whites, blacks had higher risk of recurrent ischemic stroke (Hazard Ratio [HR] 1.36, 95% Confidence Interval [CI] 1.29-1.44). Using another 5% sample from CMS (2007- 2013) for beneficiaries with prescription drug coverage, we observed that blacks were more likely than whites to be non-adherent to statins following hospitalization for ischemic stroke (adjusted RR 1.14, 95%CI 1.01-1.29). Using data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, we observed that outside the Stroke Belt, blacks were more likely than whites to be discharged on a statin (RR 1.42, 95%CI 1.04-1.94), while no black-white association was present among Stroke Belt residents (RR 0.93, 95%CI 0.69-1.26; p for interaction=0.228). In conclusion, this dissertation examines black-white differences in recurrent ischemic stroke, statin adherence, and discharge statin prescribing. Evaluating these black-white differences may help identify populations at high risk and assist in the development of interventions that can improve adherence and reduce disparities among ischemic stroke survivors.

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