. 2015 Aug;105(8):e16–e26. doi: 10.2105/AJPH.2015.302698

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.