TABLE 2—
Stroke Mortality in American Indians and Alaska Natives: Regional and National Studies, United States, 1992–2014
| Study | Sample | Data Source | Stroke Mortality | Remarks |
| Southwest | ||||
| Sievers et al.59 | 5131 Pima Indians, 1975–1984 | ICD-9 codes 431.0–434.9 and 436 on death certificates, medical records | AI 1.3/1000 | Age- and sex-adjusted rates per 1000; racial misclassification unlikely. |
| Kattapong and Becker15 | NHW, Hispanic, and AI residents of New Mexico (including Apache, Pueblo, Navajo, Zuni), 1958–1987 | ICD-9 codes 430–438.9 on death certificates, medical records | AI/AN 52.2 in 1957; 31.3 in 1983 | Age- and sex-adjusted rates per 100 000; in all years, stroke mortality was lower in AI than in Hispanic and NHW. |
| Sievers et al.60 | 5284 Pima Indians, 1965–1989 | ICD-9 codes 431.0–434.9 and 436 on death certificates, medical records | AI 4.6/1000 in patients without diabetes, 1.3/1000 in patients with diabetes | Age-adjusted rates reported per 1000 in terms of sex and diabetes status; racial misclassification unlikely. |
| Hoehner et al.61 | 4623 Pima Indians, 1965–1998 | ICD-9 codes 431.0–434.9 and 436 on death certificates, medical records | Rates reported separately for patients with and without diabetes in 8-y intervals | Racial misclassification unlikely; no calculation of overall stroke mortality. |
| Midwest and Mountain West | ||||
| Reeves et al.62 | AI/AN and NHW Wisconsin residents, 1984–1993 | ICD-9 codes 430–438 on state death records | For men aged 45–65 y, age-specific incidence-density mortality rates per 100 000 were 40.9 for AI/AN, 27.4 for NHW; for men aged > 65 y, 463.2 for AI/AN, 396.9 for NHW | Rates presented separately by sex and age; no calculation of overall stroke mortality; likely racial misclassification acknowledged. |
| Harwell et al.55 | AI/AN and NHW Montana residents, 1991–2000 | ICD-9 codes 430–434 and 436–438 and ICD-10 codes I60–I69 on state death records | In 1991–1995, AI/AN 80, NHW 64; in 1996–2000, AI/AN 81, NHW 60 | Age-adjusted rates presented per 100 000; age-specific results demonstrate much higher stroke mortality for AI/AN than NHW aged < 65 y. |
| Southeast | ||||
| Sergeev16 | Four racial/ethnic groups in Appalachia (undefined), 2000–2006 | CDC, NCHS | AI 24.8, NHW 97.5, African American 100.2, Asian 18.7 | Unadjusted rates presented per 100 000; very small AI sample, racial misclassification likely but not acknowledged. |
| Alaska | ||||
| Schumacher et al.63 | AN residents of Alaska, 1979–1998 | Alaska Division of Public Health | In 1998, AN 38 | Age-adjusted rates presented per 100 000; AN mortality higher than NHW since 1984. |
| Horner et al.64 | AN and NHW residents of Alaska, 1984–2003 | ICD-9 codes 430–434 and 436–438 and ICD-10 codes I60–I69 on death certificates | In 1984–1993, AN 71.2, NHW 64.1; in 1994–2003, AN 74.5, NHW 60.3 | Age-adjusted rates presented per 100 000 for 2 different intervals. |
| National and multiregional | ||||
| Welty et al.65 | 11 IHS regions nationwide, 1981–1983 | IHS, NCHS; ICD-9 codes 430–438 on death certificates | 32.3 across all IHS regions, ranging from 52.2 in Alaska and 50.9 in Nashville, TN, to 25.1 in Tucson, AZ, and 19.1 in Navajo Nation | Age-adjusted rates presented per 100 000; stroke mortality varied widely across IHS regions; racial misclassification on death records was acknowledged even in these regions. |
| Gillum17 | National, 1988–1990 | NHANES | Mortality substantially lower among AI/AN than among NHW and African American | No individual rates reported; racial misclassification documented in NHANES sample. |
| Lee et al.66 | 7327 AI in Arizona, Oklahoma, North Dakota, and South Dakota, 1984–1988 | Strong Heart Study | 4/1000 | Five-year, age-adjusted rate for men and women aged 45–74 y; rates were highest in ND and SD; racial misclassification unlikely. |
| Ayala et al.18 | National, 1995–1998 | ICD-9 codes 433–434 and 436–438 on NVSS death certificates | AI/AN 48.6, NHW 73.7, African American 95.8 | Age- and sex-adjusted rates presented per 100 000 for ischemic stroke; likely racial misclassification acknowledged. |
| Keppel et al.19 | National, 1990–1998 | ICD-9 codes 430–438 on NVSS death certificates | In 1998, AI/AN 19.1, NHW 23.3, African American 42.5, Hispanic 19.0 | Age-adjusted rates presented per 100 000; likely racial misclassification acknowledged. |
| Casper et al.67 | National, 1991–1998 | ICD-9 codes 430–438 on NVSS death certificates | AI/AN 79 | Age-adjusted rate per 100 000 for people aged ≥ 35 y; likely racial misclassification acknowledged. |
| CDC10 | National sample < 75 y, 2002 | ICD-10 codes I60–I69 on death certificates | AI/AN 37.5, NHW 54.2, African American 76.3, Hispanic 41.3, API 29.4 | Age-adjusted rates presented per 100 000; stroke death before age 65 occurred disproportionately in minority populations; likely racial misclassification acknowledged. |
| Rhoades25 | National, 1989–1998 | IHS vital event data | For 1996–1998, AI/AN 26.2 and NHW 13.1 for ages 45–54 y; AI/AN 60.8 and NHW 36.9 for ages 55–64 y; AI/AN 346.4 and NHW 411.3 for ages ≥ 65 y | Mortality rates presented per 100 000, with correction for racial misclassification, for AI/AN, NHW, and all-races populations for 3 age categories and 4 reporting periods. |
| Mensah et al.20 | National, 2003 | CDC | AI/AN 41.3, NHW 56.4, African American 78.8, Hispanic 44.9, API 51.2 | Age-adjusted rates presented per 100 000; likely racial misclassification acknowledged. |
| Lackland et al.21 | National, 1999–2010 | CDC | AI/AN stroke mortality < 40/100 000 since 2007 | Stroke data summarized in a graph (their Figure 2); AI/AN mortality rates consistently lower than African American and NHW; no mention of racial misclassification. |
| Schieb et al.56 | National, 1999–2009 | IHS, NVSS | Overall AI/AN 115.5, with regional rates ranging from 144.3 in Alaska and 141.6 in Oklahoma, Kansas, and Texas to 78.3 in the Southwest | Age-adjusted mortality data per 100 000 from 637 counties designated by IHS as contract health service delivery areas, corrected for racial misclassification. |
Note. AI = American Indian; AN = Alaska Native; API = Asian/Pacific Islander; CDC = Centers for Disease Control and Prevention; ICD-9 = International Classification of Diseases, 9th Revision68; ICD-10 = International Classification of Diseases, 10th Revision69; IHS = Indian Health Service; NCHS = National Center for Health Statistics; NHANES = National Health and Nutrition Examination Survey; NHW = non-Hispanic White; NVSS = National Vital Statistics System.