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Corches CL, McBride AC, Robles MC, Rehman N, Bailey S, Oliver A, Skolarus LE. Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention. Am J Health Behav 2020; 44:744-755. [PMID: 33081873 DOI: 10.5993/ajhb.44.6.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.
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Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke 2020; 51:3433-3439. [PMID: 33104471 DOI: 10.1161/strokeaha.120.030426] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We write this article amid a global pandemic and a heightened awareness of the underlying structural racism in the United States, unmasked by the recent killing of George Floyd and multiple other unarmed Black Americans (Spring 2020). Our purpose is to highlight the role of social determinants of health (SDOH) on stroke disparities, to inspire dialogue, to encourage research to deepen our understanding of the mechanism by which SDOH impact stroke outcomes, and to develop strategies to address SDOH and reduce stroke racial/ethnic disparities. We begin by defining SDOH and health disparities in today's context; we then move to discussing SDOH and stroke, particularly secondary stroke prevention, and conclude with possible approaches to addressing SDOH and reducing stroke disparities. These approaches include (1) building on prior work; (2) enhancing our understanding of populations and subpopulations, including intersectionality, of people who experience stroke disparities; (3) prioritizing populations and points along the stroke care continuum when racial/ethnic disparities are most prominent; (4) understanding how SDOH impact stroke disparities in order to test SDOH interventions that contribute to the disparity; (5) partnering with communities; and (6) exploring technological innovations. By building on the prior work and expanding efforts to address SDOH, we believe that stroke disparities can be reduced.
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Springer MV, Corches CL, McCracklin B, Scott M, Robles MC, Skolarus LE. Expanding Stroke Preparedness to Vulnerable Populations: A Music Video for the Deaf Community. J Am Heart Assoc 2020; 9:e018352. [PMID: 33032499 PMCID: PMC7763368 DOI: 10.1161/jaha.120.018352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Acute stroke treatments reduce disability after stroke, but eligibility for these treatments depends on rapid hospital arrival after symptom onset. Stroke preparedness interventions teach stroke symptoms and the importance of calling 911, thereby increasing patient eligibility for stroke treatments. Stroke preparedness interventions for the Deaf community are lacking. We sought to adapt a stroke preparedness music video, which was initially created for the hearing, for the Deaf community. Methods and Results We used a community‐engaged approach, partnering with members of the Deaf community, to adapt the video over 4 months. Adaptation involved assessing the comprehensibility and appropriateness of the video and interpreting the song lyrics into American Sign Language. Conclusions We collaborated with the Deaf community to create a stroke preparedness video for the Deaf. Future research will involve refining the video and testing its efficacy to increase stroke symptom recognition and intent to call 911.
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Skolarus LE, Lin CC, Springer MV, Burke JF. Advance care planning among stroke survivors in the United States. Neurology 2020; 95:874-876. [PMID: 32928975 DOI: 10.1212/wnl.0000000000010832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/06/2020] [Indexed: 11/15/2022] Open
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Merid B, Whitfield CO, Skolarus LE. Reflections on the Values of Community-Based Participatory Research in Supporting Mobile Health Technology Use. Circ Cardiovasc Qual Outcomes 2020; 13:e007131. [PMID: 32885680 DOI: 10.1161/circoutcomes.120.007131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Brenner AB, Skolarus LE, Perumalswami CR, Burke JF. Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans. J Pain Symptom Manage 2020; 60:595-601.e3. [PMID: 32376264 PMCID: PMC7483277 DOI: 10.1016/j.jpainsymman.2020.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL). METHODS This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models. RESULTS Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability. CONCLUSIONS Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.
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Skolarus LE, Lin CC, Kerber KA, Burke JF. Regional Variation in Billed Advance Care Planning Visits. J Am Geriatr Soc 2020; 68:2620-2628. [PMID: 32805062 DOI: 10.1111/jgs.16730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/11/2020] [Accepted: 06/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Advance care planning (ACP) is associated with improved patient and caregiver outcomes, but is underutilized. To encourage ACP, the Centers for Medicare & Medicaid Services implemented specific ACP visit reimbursement codes in 2016. To better understand the utilization of these ACP reimbursement codes, we explored regional variation in billed ACP visits. DESIGN We performed a retrospective cross-sectional analysis using a randomly sampled 5% cohort of Medicare fee-for-service (FFS) beneficiaries' claims files from 2017. Region was defined by hospital referral region. SETTING National Medicare FFS. PARTICIPANTS A total of 1.3 million Medicare beneficiaries aged 65 years and older. MEASUREMENT Receipt of billed ACP service, identified through Current Procedural Terminology code 99497 or 99498. Proportion of beneficiaries who received billed ACP service(s) by region was calculated. We fit a multilevel logistic regression model with a random regional intercept to determine the variation in billed ACP visits attributable to the region after accounting for patient (demographics, comorbidities, and medical care utilization) and regional factors (hospital size, emergency department visits, hospice utilization, and costs). RESULTS The study population included about 1.3 million beneficiaries, of which 32,137 (2.4%) had at least one billed ACP visit in 2017. There was substantial regional variation in the percentage of beneficiaries with billed ACP visits: lowest quintile region, less than 0.83%; subsequent regions, less than 1.6%, less than 2.4%, less than 3.3% to less than 8.4% in the highest quintile regions. A total of 15.4% of the variance in whether an older adult had a billed ACP visit was explained by the region. Although numerous regional factors were associated with billed ACP visits, none were strong predictors. CONCLUSION In 2017, we found wide regional variation in the use of billed ACP visits, although use overall was low in all regions. Increasing the understanding of the drivers and the effects of billed ACP visits could inform strategies for increasing ACP.
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Sozener CB, Lisabeth LD, Shafie-Khorassani F, Kim S, Zahuranec DB, Brown DL, Skolarus LE, Burke JF, Kerber KA, Meurer WJ, Case E, Morgenstern LB. Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites. Stroke 2020; 51:2428-2434. [PMID: 32673520 DOI: 10.1161/strokeaha.120.029376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study. METHODS Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms. RESULTS From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]). CONCLUSIONS Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.
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Stamm BJ, Burke JF, Lin CC, Price RJ, Skolarus LE. Disability in Community-Dwelling Older Adults: Exploring the Role of Stroke and Dementia. J Prim Care Community Health 2020; 10:2150132719852507. [PMID: 31185786 PMCID: PMC6563403 DOI: 10.1177/2150132719852507] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: We sought to determine the relative contributions of stroke, dementia, and their combination to disability and racial differences in disability among community-dwelling older adults. Methods: We performed a cross-sectional study of 6848 community-dwelling older adults. We evaluated the associations of stroke, dementia, and their combination with activities of daily living (ADL) limitations (range 0-7). We then explored the impact of stroke and dementia on race differences in ADL limitations using Poisson regression after accounting for sociodemographics and comorbidities. Results: After full adjustment, ADL limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 (95% CI 0.29-0.35) ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination -1.48% (95%CI -2.21% to -0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability.
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Skolarus LE, Feng C, Burke JF. Exploring Factors Contributing to Race Differences in Poststroke Disability. Stroke 2020; 51:1813-1819. [PMID: 32404036 DOI: 10.1161/strokeaha.119.027700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods- A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009-2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0-7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results- There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7-2.2]; P=0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2-2.4]; P=0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0-3.2] in blacks versus 1.4 [1.0-1.8] in whites, mean difference, 1.2 [0.5-1.9], P<0.001) and immediately poststroke (2.6 [2.0-3.3] in blacks versus 1.7 [1.2-2.1] in whites, mean difference, 1.0 [0.2-1.7], P<0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions- Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.
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Dong L, Sánchez BN, Skolarus LE, Stulberg E, Morgenstern LB, Lisabeth LD. Sex difference in prevalence of depression after stroke. Neurology 2020; 94:e1973-e1983. [PMID: 32312890 PMCID: PMC7282882 DOI: 10.1212/wnl.0000000000009394] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/16/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE This study investigated the sex difference in prevalence of depression at 90 days after first-ever stroke. METHODS Patients with first-ever stroke (n = 786) were identified from the population-based Brain Attack Surveillance in Corpus Christi project (2011-2016). Poststroke depressive symptoms were assessed by the 8-item Patient Health Questionnaire, and prestroke depression status (history and medication use) was self-reported. Logistic regression was used to examine the association between sex and depression after stroke, and effect modification by prestroke depression status, accounting for missing data. RESULTS Women were more likely to have a history of and be on medication for depression at the time of stroke than men (p < 0.001). Prevalence of depression at 90 days was 28.2% for men (95% confidence interval [CI], 23.7%-32.8%) and 32.7% for women (95% CI, 27.8%-37.5%). The age-adjusted odds ratio (OR) of depression after stroke comparing women and men was 1.34 (95% CI, 0.97-1.85), and fully attenuated after adjustment for sociodemographic, stroke, and prestroke characteristics. Effect modification by prestroke depression status was present (p = 0.038). Among participants on medication for depression at the time of stroke, women were significantly less likely to have depression at 90 days compared with men (OR, 0.39; 95% CI, 0.16-0.96), whereas significant sex differences were not noted among those with and without a depression history. CONCLUSION The sex difference in prevalence of depression at 90 days after first-ever stroke was not significant overall, but varied by prestroke depression status. Interventions to address and prevent poststroke depression are needed, particularly among those with prestroke depression but not undergoing treatment for depression at stroke onset.
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Abstract
IMPORTANCE Assessment of functional outcomes is currently limited by a lack of large data sets. Functional assessments are included in Medicare rehabilitation assessment files, yet the validity of these measures in routine care is unknown. OBJECTIVE To evaluate the validity of individual-level routine care functional assessments in Medicare rehabilitation settings compared with criterion-standard National Health and Aging Trends Study (NHATS) research assessments obtained no more than 90 days later. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of individuals aged 65 years and older used the 2011 to 2015 NHATS linked with Medicare assessment files. Individuals with a discharge assessment from inpatient rehabilitation facilities, skilled nursing facilities, or home health agencies and a criterion-standard NHATS assessment were included. Data analysis was performed June 2019 to November 2019. MAIN OUTCOMES AND MEASURES Summary functional assessment based on independence with eating, toilet hygiene, bathing, dressing, transfers, and mobility or walking. Linear regression was used to assess agreement between the 2 scales, adjusting for time between assessments and rehabilitation setting. RESULTS A total of 1036 adults aged 65 years and older (671 [64.8%] aged ≥80 years; 670 [64.7%] women; 685 [66.1%] white participants) met the study criteria. The correlation of the assessments was 0.63 (95% CI, 0.59 to 0.66; mean [SD] rehabilitation score, 27.5 [7.2]; mean [SD] NHATS score, 30.5 [10.1]). The correlation increased to 0.66 (95% CI, 0.60 to 0.71) for assessments no more than 30 days apart. The linear regression model adjusting for rehabilitation setting and days between evaluations found the assessments were strongly correlated (β = 1.00 [95% CI, 0.93 to 1.08]; intercept, 0.72 [95% CI, -1.79 to 3.24]; R2 = 0.42). Differences in scores were generally small (mean [SD] of NHATS - rehabilitation score, 2.96 [7.91]), and only 59 assessments (5.7%) differed by more than 2 SDs of the mean difference. Rehabilitation service scores were typically higher than NHATS scores in individuals with lower mean scores; however, the population with lower mean scores was small (156 [15.1%]). CONCLUSIONS AND RELEVANCE In this large sample of older US adults, routine care rehabilitation facility functional assessments had overall moderate correlation with criterion-standard research assessments.
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Champoux E, Price R, Cowdery JE, Dinh M, Meurer WJ, Rehman N, Schille C, Oliver A, Brown DL, Killingsworth J, Skolarus LE. Reach Out Emergency Department: Partnering With an Economically Disadvantaged Community in the Development of a Text-Messaging Intervention to Address High Blood Pressure. Health Promot Pract 2020; 21:791-801. [PMID: 32228238 DOI: 10.1177/1524839920913550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Hypertension affects nearly 30% of the U.S. adult population. Due to the ubiquitous nature of mobile phone usage, text messaging offers a promising platform for interventions to assist in the management of chronic diseases including hypertension, including among populations that are historically underserved. We present the intervention development of Reach Out, a health behavior theory-based, mobile health intervention to reduce blood pressure among hypertensive patients evaluated in a safety net emergency department primarily caring for African Americans. Aims. To describe the process of designing and refining text messages currently being implemented in the Reach Out randomized controlled trial. Method. We used a five-step framework to develop the text messages used in Reach Out. These steps included literature review and community formative research, conception of a community-centered behavioral theoretical framework, draft of evidence-based text messages, community review, and revision based on community feedback and finalization. Results. The Reach Out development process drew from pertinent evidence that, combined with community feedback, guided the development of a community-centered health behavior theory framework that led to development of text messages. A total of 333 generic and segmented messages were created. Messages address dietary choices, physical activity, hypertension medication adherence, and blood pressure monitoring. Discussion. Our five-step framework is intended to inform future text-messaging-based health promotion efforts to address health issues in vulnerable populations. Conclusion. Text message-based health promotion programs should be developed in partnership with the local community to ensure acceptability and relevance.
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Reynolds EL, Burke JF, Banerjee M, Kerber KA, Skolarus LE, Magliocco B, Esper GJ, Callaghan BC. Association of out-of-pocket costs on adherence to common neurologic medications. Neurology 2020; 94:e1415-e1426. [PMID: 32075894 PMCID: PMC7274913 DOI: 10.1212/wnl.0000000000009039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/04/2019] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To determine the association between out-of-pocket costs and medication adherence in 3 common neurologic diseases. METHODS Utilizing privately insured claims from 2001 to 2016, we identified patients with incident neuropathy, dementia, or Parkinson disease (PD). We selected patients who were prescribed medications with similar efficacy and tolerability, but differential out-of-pocket costs (neuropathy with gabapentinoids or mixed serotonin/norepinephrine reuptake inhibitors [SNRIs], dementia with cholinesterase inhibitors, PD with dopamine agonists). Medication adherence was defined as the number of days supplied in the first 6 months. Instrumental variable analysis was used to estimate the association of out-of-pocket costs and other patient factors on medication adherence. RESULTS We identified 52,249 patients with neuropathy on gabapentinoids, 5,246 patients with neuropathy on SNRIs, 19,820 patients with dementia on cholinesterase inhibitors, and 3,130 patients with PD on dopamine agonists. Increasing out-of-pocket costs by $50 was associated with significantly lower medication adherence for patients with neuropathy on gabapentinoids (adjusted incidence rate ratio [IRR] 0.91, 0.89-0.93) and dementia (adjusted IRR 0.88, 0.86-0.91). Increased out-of-pocket costs for patients with neuropathy on SNRIs (adjusted IRR 0.97, 0.88-1.08) and patients with PD (adjusted IRR 0.90, 0.81-1.00) were not significantly associated with medication adherence. Minority populations had lower adherence with gabapentinoids and cholinesterase inhibitors compared to white patients. CONCLUSIONS Higher out-of-pocket costs were associated with lower medication adherence in 3 common neurologic conditions. When prescribing medications, physicians should consider these costs in order to increase adherence, especially as out-of-pocket costs continue to rise. Racial/ethnic disparities were also observed; therefore, minority populations should receive additional focus in future intervention efforts to improve adherence.
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Appukutty AJ, Skolarus LE, Springer MV, Meurer WJ, Burke JF. Abstract 88: Increasing False Positive Diagnoses May Lead to Overestimation of Stroke Incidence, Particularly in the Young. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Stroke incidence is reportedly increasing in younger adults. While increasing vascular risk factor prevalence has been suggested as a cause, the reasons for rising stroke incidence in the young are not clear. We explored several alternate explanations: trends in neurologically-focused emergency department (ED) visits, differential diagnostic classification of stroke and TIA over time, and changes in the use of advanced imaging in young and older adults.
Methods:
We performed a retrospective, serial, cross-sectional study on a nationally representative sample of all ED visits in the United States to quantify changes in patterns of neurologically-focused ED visits, stroke and TIA diagnoses, and rates of MRI utilization for young (18 – 44 years) and older (65+ years) adults over a 17-year period (1995 – 2000; 2005 – 2015) using National Hospital Ambulatory Medical Care Survey (NHAMCS) data.
Results:
In young adults, 0.4% (95% CI 0.3% – 0.5%) of neurologically-focused ED visits resulted in a primary diagnosis of stroke vs. 6.8% (95% CI 6.2% – 7.5%) for older adults. In both populations, the incidence of neurologically-focused ED visits has increased over time (+111/100,000 population/year, 95% CI +94 – +130 in the young vs. +70/100,000 population/year, 95% CI +34 – +108 in older adults). There was no evidence of differential classification of TIA to stroke over time (OR 1.001 per year, 95% CI 0.926 – 1.083 in the young; OR 1.003 per year, 95% CI 0.982 – 1.026 in older adults) and no evidence of disproportionate rise in MRI utilization for neurologically-focused ED visits in the young (OR 1.057 per year, 95% CI 1.028 – 1.086 in the young; OR 1.095 per year, 95% CI 1.066 – 1.125 in older adults).
Conclusions:
If the specificity of stroke diagnosis amongst ED visits is similar amongst young and older populations, then the combination of data observed here, including (1) a lower prior probability of stroke diagnoses in the young and (2) an increasing trend in neurologically-focused ED visits in both age groups, suggests that false positive diagnoses will increase over time, with a faster rise in the young compared to older adults. These data suggest a potential explanation that may contribute to higher stroke incidence in the young and merits further scrutiny.
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Skolarus LE, Cielito Robles M, Mellanie S, Lin CC, Corches C, Oliver A, Burke J. Abstract WP221: Very Brief Intervention Improves Stroke Response in a Randomized Trial: Stroke Ready Very Brief Intervention. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Stroke pre-hospital delay has not improved over time.
Hypothesis:
Stroke Ready, a very brief (5 minute), theory based, peer-led, stroke preparedness intervention, will increase stroke response compared with a control intervention.
Methods:
We performed a randomized, single-blind controlled trial among adults in Flint, MI. The stroke preparedness intervention group received a Stroke Ready pamphlet and action plan, while the control group received stroke prevention materials - both delivered during a one-to-one interaction with a trained peer educator. Research staff, blinded to group intervention assignment, assessed baseline and immediate post-intervention outcomes. Primary outcome was change in stroke response (behavioral intent to call 911) using a community-modified stroke action test (range 0-12). Secondary outcome was change in stroke symptom recognition (range 0-8). We conducted descriptive analyses and used a linear regression model to evaluate the effect of the intervention on stroke response after adjustment for pre-intervention intent, age, education, race, marital status, history of stroke, stroke in someone they know and psychological constructs.
Results:
We enrolled 129 participants (74 intervention; 55 control). Mean age was 60 years (SD 14); 61% were women, 89% were African American and 19% were not high school graduates. Intervention participants had greater improvement in stroke response than control participants (figure 1), which remained after full adjustment (improvement in average score for stroke response was 1.7 higher in intervention participants than control participants, 95% CI 0.9-2.5, p<0.0001). There was no difference in stroke symptom recognition (figure 1).
Conclusion:
The Stroke Ready very brief intervention increased stroke response. This new approach using a very brief, one-to-one interaction with trained peer educators is a promising, scalable, intervention to increase stroke response.
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Clery A, Bhalla A, Bisquera A, Skolarus LE, Marshall I, McKevitt C, Rudd A, Sackley C, Martin FC, Manthorpe J, Wolfe C, Wang Y. Long-Term Trends in Stroke Survivors Discharged to Care Homes: The South London Stroke Register. Stroke 2020; 51:179-185. [PMID: 31690255 PMCID: PMC6924949 DOI: 10.1161/strokeaha.119.026618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/24/2019] [Accepted: 10/02/2019] [Indexed: 01/09/2023]
Abstract
Background and Purpose- Care homes provide care to many stroke survivors, yet little is known about changes in care home use over time. We aim to determine trends in discharge to care homes, to explore the characteristics of stroke survivors over time (1995-2018), and to identify the associations between these characteristics and discharge to care homes poststroke. Methods- Using data from the South London Stroke Register between 1995 and 2018, we estimated the proportions discharged to care homes and their characteristics over time, assessed by tests for trends. Multivariable logistic regression models were built to assess the associations between their characteristics and discharge destination. Results- Of 4172 stroke survivors, 484 (12%) were discharged to care homes. This proportion has decreased from 24% in 1995 to 2000 to 5% in 2013 to 2018. The mean age of those discharged to care homes has increased over time, from 73 to 75 (P<0.001). Among stroke survivors discharged to a care home, the proportion with a prestroke Barthel Index <15 has also increased over time from 7% to 21% (P=0.027), while the proportion with a 7-day poststroke Barthel Index <15 remains largely unchanged over time (93% in 1995-2000, 90% in 2013-2018). The characteristics most strongly associated with discharge to care homes were (odds ratio [95% CI]) age (1.05 [1.04-1.07] per year), stroke subtype (hemorrhagic; 0.64 [0.43-0.95]), stroke severity (Glasgow Coma Scale score, <13; 1.67 [1.19-2.35]), failed swallow test at admission (1.65 [1.20-2.25]), 7-day poststroke Barthel Index <15 (3.58 [2.20-6.03]), and a longer hospital stay (1.02 [1.02-1.03] per day). Conclusions- Over >20 years, there has been an 80% reduction in the proportion of stroke survivors discharged to care homes, influenced by changes in the demographics, disability, and stroke care in the underlying stroke population. In those moving to care homes, the level of poststroke disability remains high, requiring continued attention and investment.
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Price RJ, Brenner AB, Lin CC, Burke JF, Skolarus LE. Two million stroke survivors utilize medical visit companions: The other person in the room? Neurology 2019; 93:899-901. [PMID: 31619484 DOI: 10.1212/wnl.0000000000008465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/20/2019] [Indexed: 11/15/2022] Open
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Burke JF, Feng C, Skolarus LE. Divergent poststroke outcomes for black patients: Lower mortality, but greater disability. Neurology 2019; 93:e1664-e1674. [PMID: 31554649 PMCID: PMC6946478 DOI: 10.1212/wnl.0000000000008391] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 06/03/2019] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To explore racial differences in disability at the time of first postdischarge disability assessment. METHODS This was a retrospective cohort study of all Medicare fee-for-service beneficiaries hospitalized with primary ischemic stroke (ICD-9,433.x1, 434.x1, 436) or intracerebral hemorrhage (431) diagnosed from 2011 to 2014. Racial differences in poststroke disability were measured in the initial postacute care setting (inpatient rehabilitation facility, skilled nursing facility, or home health) with the Pseudo-Functional Independence Measure. Given that assignment into postacute care setting may be nonrandom, patient location during the first year after stroke admission was explored. RESULTS A total of 390,251 functional outcome assessments (white = 339,253, 87% vs black = 50,998, 13%) were included in the primary analysis. At the initial functional assessment, black patients with stroke had greater disability than white patients with stroke across all 3 postacute care settings. The difference between white and black patients with stroke was largest in skilled nursing facilities (black patients 1.8 points lower than white patients, 11% lower) compared to the other 2 settings. Conversely, 30-day mortality was greater in white patients with stroke compared to black patients with stroke (18.4% vs 12.6% [p < 0.001]) and a 3 percentage point difference in mortality persisted at 1 year. Black patients with stroke were more likely to be in each postacute care setting at 30 days, but only very small differences existed at 1 year. CONCLUSIONS Black patients with stroke have 30% lower 30-day mortality than white patients with stroke, but greater short-term disability. The reasons for this disconnect are uncertain, but the pattern of reduced mortality coupled with increased disability suggests that racial differences in care preferences may play a role.
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Stulberg EL, Dong L, Zheutlin AR, Kim S, Claflin ES, Skolarus LE, Morgenstern LB, Lisabeth LD. Associations of Self-Reported History of Depression and Antidepressant Use Before Stroke Onset With Poststroke Post-Acute Rehabilitation Care-An Exploratory Study: The BASIC (Brain Attack Surveillance in Corpus Christi) Project. J Am Heart Assoc 2019; 8:e013382. [PMID: 31423875 PMCID: PMC6759886 DOI: 10.1161/jaha.119.013382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Prestroke depression status and post–acute rehabilitation care (PARC) are determinants of poststroke depression and function. However, little is known on how prestroke depression status affects PARC placement, a possible pathway for upstream intervention. We examined how prestroke depression status affects PARC in a population‐based study. Methods and Results Incident ischemic stroke cases were from the BASIC (Brain Attack Surveillance in Corpus Christi) Project from 2008 to 2012. Prestroke depression status was self‐reported and categorized as (1) never depressed, (2) history of depression without antidepressant use before stroke onset, or (3) antidepressant use before stroke onset. PARC included home, a skilled nursing facility, or an inpatient rehabilitation facility. Confounder‐adjusted multinomial regression models were used to examine the association between prestroke depression status and PARC. Adjustment for stroke severity was deferred in the main analyses because it may lie on the causal pathway. There were 548 stroke survivors (mean age 65.3 years, 48.3% female, 62.6% Mexican‐American). The adjusted odds ratios comparing home discharge to a skilled nursing facility were 1.88 (95% CI: 0.86‐4.11) for those with a history of depression and 2.55 (95% CI: 1.11‐5.83) for those using an antidepressant at stroke onset, relative to those never depressed. The adjusted odds ratios comparing an inpatient rehabilitation facility to a skilled nursing facility were 1.17 (95% CI 0.40‐3.42) and 3.28 (95% CI 1.24‐8.67) for those with a history of depression and those using an antidepressant at stroke onset, respectively, relative to those never depressed. Conclusions Antidepressant use before stroke onset may increase odds of home and inpatient rehabilitation facility discharge compared with skilled nursing facility discharge.
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Terman SW, Reeves MJ, Skolarus LE, Burke JF. Association Between Early Outpatient Visits and Readmissions After Ischemic Stroke. Circ Cardiovasc Qual Outcomes 2019; 11:e004024. [PMID: 29653998 DOI: 10.1161/circoutcomes.117.004024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 03/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmission is an important goal to optimize poststroke care and reduce costs. Early outpatient follow-up may represent one important strategy to reduce readmissions. We examined the association between time to first outpatient contact and readmission to inform postdischarge transitions. METHODS AND RESULTS We performed a retrospective cohort study of all Medicare fee-for-service patients discharged home after an acute ischemic stroke in 2012 identified by the InternationalClassification of Diseases, Ninth Revision, Clinical Modification codes. Our primary predictor variable was whether patients had a primary care or neurology visit within 30 days of discharge. Our primary outcome variable was all-cause 30-day hospital readmission. We used separate multivariable Cox models with primary care and neurology visits specified as time-dependent covariates, adjusted for numerous patient- and systems-level factors. The cohort included 78 345 patients. Sixty-one percent and 16% of patients, respectively, had a primary care and neurology visit within 30 days of discharge. Visits occurred a median (interquartile range) 7 (4-13) and 15 (5-22) days after discharge for primary care and neurology, respectively. Thirty-day readmission occurred in 9.4% of patients. Readmissions occurred a median 14 (interquartile range, 7-21) days after discharge. Patients who had a primary care visit within 30 days of discharge had a slightly lower adjusted hazard of readmission than those who did not (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98). The association was nearly identical for 30-day neurology visits (hazard ratio, 0.98; 95% confidence interval, 0.97-0.98). CONCLUSIONS Thirty-day outpatient follow-up was associated with a small reduction in hospital readmission among elderly patients with stroke discharged home. Further work should assess how outpatient care may be improved to further reduce readmissions.
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Dong L, Sánchez BN, Skolarus LE, Morgenstern LB, Lisabeth LD. Ethnic Differences in Prevalence of Post-stroke Depression. Circ Cardiovasc Qual Outcomes 2019; 11:e004222. [PMID: 29371220 DOI: 10.1161/circoutcomes.117.004222] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/21/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about ethnic differences in poststroke depression (PSD) in the United States. This study aims to estimate the prevalence of PSD at 90 days after first-ever stroke and to examine ethnic differences in the prevalence between Mexican Americans (MAs) and non-Hispanic whites (NHWs). METHODS AND RESULTS Stroke cases from 2011 to 2015 were identified from the BASIC project (Brain Attack Surveillance in Corpus Christi)-a population-based stroke surveillance study in south Texas. Participants were interviewed at the onset of stroke (baseline interview) and ≈90 days post-stroke (outcome interview). PSD was assessed by the Patient Health Questionnaire-8. Inverse probability weights were generated to account for differential attrition, and weighted logistic regression was used to investigate the association between ethnicity and PSD. The study sample consisted of 586 first-ever stroke patients who completed nonproxy baseline and outcome interviews and had depression assessment. Approximately, 60% of them were MAs, and 40% were NHWs. After accounting for attrition, the prevalence of depression at 90 days post-stroke was 30.4% for MAs (95% confidence interval, 25.0%-35.9%) and 20.7% for NHWs (95% confidence interval, 15.7%-25.7%). The crude odds of PSD in MAs was 1.69 times greater than that in NHWs (95% confidence interval, 1.13-2.51). The odds ratio decreased by 23.6% after adjustment for education (odds ratio, 1.29; 95% confidence interval, 0.82-2.02) and was further attenuated with additional adjustment for other covariates. CONCLUSIONS MAs had a higher prevalence of PSD at 90 days than NHWs. The ethnic difference was explained by sociodemographic and health factors, especially low educational attainment.
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Callaghan BC, Reynolds E, Banerjee M, Kerber KA, Skolarus LE, Magliocco B, Esper GJ, Burke JF. Out-of-pocket costs are on the rise for commonly prescribed neurologic medications. Neurology 2019; 92:e2604-e2613. [PMID: 31043472 PMCID: PMC6556089 DOI: 10.1212/wnl.0000000000007564] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/08/2019] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To determine out-of-pocket costs for neurologic medications in 5 common neurologic diseases. METHODS Utilizing a large, privately insured, health care claims database from 2004 to 2016, we captured out-of-pocket medication costs for patients seen by outpatient neurologists with multiple sclerosis (MS), peripheral neuropathy, epilepsy, dementia, and Parkinson disease (PD). We compared out-of-pocket costs for those in high-deductible health plans compared to traditional plans and explored cumulative out-of-pocket costs over the first 2 years after diagnosis across conditions with high- (MS) and low/medium-cost (epilepsy) medications. RESULTS The population consisted of 105,355 patients with MS, 314,530 with peripheral neuropathy, 281,073 with epilepsy, 120,720 with dementia, and 90,801 with PD. MS medications had the fastest rise in monthly out-of-pocket expenses (mean [SD] $15 [$23] in 2004, $309 [$593] in 2016) with minimal differences between medications. Out-of-pocket costs for brand name medications in the other conditions also rose considerably. Patients in high-deductible health plans incurred approximately twice the monthly out-of-pocket expense as compared to those not in these plans ($661 [$964] vs $246 [$472] in MS, $40 [$94] vs $18 [$46] in epilepsy in 2016). Cumulative 2-year out-of-pocket costs rose almost linearly over time in MS ($2,238 [$3,342]) and epilepsy ($230 [$443]). CONCLUSIONS Out-of-pocket costs for neurologic medications have increased considerably over the last 12 years, particularly for those in high-deductible health plans. Out-of-pocket costs vary widely both across and within conditions. To minimize patient financial burden, neurologists require access to precise cost information when making treatment decisions.
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Skolarus LE, O'Brien A, Meurer WJ, Zikmund Fisher BJ. Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics. Stroke 2019; 50:1595-1597. [PMID: 31084320 DOI: 10.1161/strokeaha.119.024653] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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McDermott M, Skolarus LE, Burke JF. A systematic review and meta-analysis of interventions to increase stroke thrombolysis. BMC Neurol 2019; 19:86. [PMID: 31053101 PMCID: PMC6500041 DOI: 10.1186/s12883-019-1298-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 04/11/2019] [Indexed: 12/22/2022] Open
Abstract
Background Although the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness. Methods We searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics. Results The search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45–2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44–2.09) for EMS, 1.58 (95% CI, 0.72–3.47) for telemedicine, and 1.89 (95% CI, 0.77–4.65) for public education, the latter not restricted to ischemic stroke patients. Conclusions Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.
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Skolarus LE, Neshewat GM, Evans L, Green M, Rehman N, Landis-Lewis Z, Schrader JW, Sales AE. Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study. BMC Health Serv Res 2019; 19:182. [PMID: 30894152 PMCID: PMC6425596 DOI: 10.1186/s12913-019-4012-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). Methods Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. Results We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. Conclusions Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis. Electronic supplementary material The online version of this article (10.1186/s12913-019-4012-6) contains supplementary material, which is available to authorized users.
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Skolarus LE, Sales AE, Zimmerman MA, Corches CL, Landis-Lewis Z, Robles MC, McBride AC, Rehman N, Oliver A, Islam N, Springer MV, O'Brien A, Bailey S, Morgenstern LB, Meurer WJ, Burke JF. Stroke Ready: a multi-level program that combines implementation science and community-based participatory research approaches to increase acute stroke treatment: protocol for a stepped wedge trial. Implement Sci 2019; 14:24. [PMID: 30845958 PMCID: PMC6407173 DOI: 10.1186/s13012-019-0869-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Post-stroke disability is common, costly, and projected to increase. Acute stroke treatments can substantially reduce post-stroke disability, but few patients take advantage of these cost-effective treatments. Practical, cost-efficient, and sustainable interventions to address underutilized acute stroke treatments are currently lacking. In this context, we present the Stroke Ready project, a stepped wedge design, multi-level intervention that combines implementation science and community-based participatory research approaches to increase acute stroke treatments in the predominately African American community of Flint, Michigan, USA. METHODS Guided by the Tailored Implementation of Chronic Disease (TICD) framework, we begin with optimization of acute stroke care in emergency departments, with particular attention given to our safety-net hospital partners. Then, we move to a community-wide, multi-faceted, stroke preparedness intervention, with workshops led by peer educators, over 2 years. Measures of engagement of the safety-net hospital and the feasibility and sustainability of the implementation strategy as well as community intervention reach, dose delivered, and satisfaction will be collected. The primary outcome is acute stroke treatment rates, which includes both intravenous tissue plasminogen activator, and endovascular treatment. The co-secondary outcomes are intravenous tissue plasminogen activator treatment rates and the proportion of stroke patients who arrive by ambulance. DISCUSSION If successful, Stroke Ready will increase acute stroke treatment rates through emergency department and community level interventions. The stepped wedge design and process evaluation will provide insight into how Stroke Ready works and where it might work best. By exploring the relative effectiveness of the emergency department optimization and the community intervention, we will inform hospitals and communities as they determine how best to use their resources to optimize acute stroke care. TRIAL REGISTRATION ClinicalTrials.gov Trial Identifier NCT03645590 .
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Carey MR, Callaghan BC, Kerber KA, Skolarus LE, Burke JF. Impact of early headache neuroimaging on time to malignant brain tumor diagnosis: A retrospective cohort study. PLoS One 2019; 14:e0211599. [PMID: 30707721 PMCID: PMC6358089 DOI: 10.1371/journal.pone.0211599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Neuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches. METHODS This was a retrospective cohort study using administrative claims data (2001-2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings. RESULTS 22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23-0.34%) of the early neuroimaging group and 0.04% (0.02-0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3-19) days versus 72 (39-189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00-3.34%) of the early neuroimaging group and 0.66% (0.58-0.74%) of the referent group (P<0.001). CONCLUSIONS Malignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.
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Lin DJ, Feng C, Skolarus LE, Burke JF. Abstract WP188: Clinical Characteristics and Therapy Content of Stroke Patients admitted to Inpatient Rehabilitation Facility versus Skilled Nursing Facility. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Post-stroke functioning is thought to be a key factor in selection of inpatient post-acute care setting after stroke (i.e. inpatient rehabilitation facility, IRF, or skilled nursing facility, SNF), but significant practice variation exists. There is also limited data on how therapy intensity differs between IRF and SNF. Here we describe the characteristics of patients admitted to IRF versus SNF and analyze the therapy content at each setting.
Methods:
This was a retrospective study of Medicare fee-for-service beneficiaries hospitalized in 2011 with a primary acute hospital stroke diagnosis (ICD-9 CM 431, 433.x1, 434.x1, 436). We quantified patient characteristics on admission to each setting and minutes of therapy using Medicare standard analytic files. The main outcome measures were Functional Independence Measure (FIM) in IRF settings and Pseudo-FIM (a cross-walk referenced score based on FIM-like assessments) in SNF settings.
Results:
Of the stroke hospitalizations in 2011, 31957 patients were discharged to IRF and 28327 to SNF. SNF patients were more likely to have dementia and g-tubes, while IRF patients were more likely to have received tPA. The initial FIM/pseudo-FIM motor and ADL scores were similar across the two populations mean (SD)— 24.3 (9.7) motor, 17.4 (6.8) ADL for IRF; 25.4 (8.3) motor, 16.5 (5.6) ADL for SNF. Patients at IRF received a mean of 906.9 minutes (median 832, IQR 712.4) of therapy over 15.5 (7.6) days, while patients at SNF received a mean of 785.8 minutes (median 585.1, IQR 708.4) over 29.3 (28.6) days. 34% of SNF patients received more total PT minutes than the median IRF patient.
Conclusions:
Surprisingly, baseline function was quite similar between stroke patients discharged to a SNF or an IRF. Also, because the average length of stay at SNF was much longer, the total amount of therapy received by patients between IRF and SNF was similar. This practice pattern variation may be a tool to identify optimal rehabilitation strategies.
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Burke JF, Skolarus LE. Are More Young People Having Strokes?-A Simple Question With an Uncertain Answer. JAMA Neurol 2019; 74:639-641. [PMID: 28395081 DOI: 10.1001/jamaneurol.2017.0161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Callaghan BC, Burke JF, Skolarus LE, Kerber KA. Assessment of Proposed Changes to Evaluation and Management Billing Levels by Physician Specialty. JAMA Neurol 2019; 76:231-232. [PMID: 30383157 DOI: 10.1001/jamaneurol.2018.3794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hill CE, Lin CC, Burke JF, Kerber KA, Skolarus LE, Esper GJ, Magliocco B, Callaghan BC. Claims data analyses unable to properly characterize the value of neurologists in epilepsy care. Neurology 2019; 92:e973-e987. [PMID: 30674587 DOI: 10.1212/wnl.0000000000007004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy. METHODS Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery). RESULTS After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, p < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, p < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases (p ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases (p ≤ 0.001). CONCLUSIONS Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.
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Lank RJ, Lisabeth LD, Sánchez BN, Zahuranec DB, Kerber KA, Skolarus LE, Burke JF, Levine DA, Case E, Brown DL, Morgenstern LB. Recurrent stroke in midlife is associated with not having a primary care physician. Neurology 2019; 92:e560-e566. [PMID: 30610095 DOI: 10.1212/wnl.0000000000006878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/08/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine using a population-based study whether midlife stroke patients having a primary care physician (PCP) at the time of first stroke have a lower risk of stroke recurrence and mortality than those who do not have a PCP. METHODS First-ever ischemic stroke patients 45 to 64 years of age at stroke onset were ascertained through the Brain Attack Surveillance in Corpus Christi (BASIC) project from 2000 to 2013 in Texas. Cox proportional hazards models were used to examine the association between not having a PCP and stroke recurrence or all-cause mortality in separate models. Cases were followed up for up to 5 years or until December 31, 2013, whichever came first. Cases were censored for recurrence if they died before experiencing a recurrent event. We adjusted for clinical risk factors that could be associated with having a PCP and recurrence or mortality. RESULTS There were 663 first-occurrence ischemic stroke cases. Of these, 77% had a PCP, 43% were female, and average age was 55.6 years. Five-year recurrence risk was 14.6%, and mortality risk was 19.2%. Not having a PCP was associated with higher recurrence risk (adjusted hazard ratio 1.75, 95% confidence interval 1.02-3.02). Having a PCP was not associated with mortality. Sensitivity analyses showed that results were robust to different ways to adjust for chronic conditions. CONCLUSION This study found lower rates of stroke recurrence among those with a PCP at the time of first stroke. Future studies could determine the value of establishing a PCP before stroke hospital discharge for secondary stroke prevention.
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Braley TJ, Dunietz GL, Chervin RD, Lisabeth LD, Skolarus LE, Burke JF. Recognition and Diagnosis of Obstructive Sleep Apnea in Older Americans. J Am Geriatr Soc 2018; 66:1296-1302. [PMID: 29744855 DOI: 10.1111/jgs.15372] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To estimate the proportion of older Americans at risk for obstructive sleep apnea (OSA) who receive OSA evaluations, diagnosis, and treatment. DESIGN Cross sectional study. SETTING National Health and Aging Trends Study (NHATS), Round 3 survey. PARTICIPANTS Community-dwelling Medicare beneficiaries age 65 and older (N=1,052). MEASUREMENTS NHATS participants were asked specific questions about sleep disturbances, including items that resembled critical elements of a validated instrument used to assess OSA risk (the STOP-Bang questionnaire). The proportion of older Americans at risk for OSA who received evaluations with home or in-laboratory sleep studies, OSA diagnosis, and OSA treatment was examined, as well as clinical, social, and demographic correlates of OSA. RESULTS Of 1,052 participants who completed the sleep module, 56% (95% confidence interval (CI)=53-59%) were estimated to be at high risk of OSA. Only 8% (95% CI=5-11%) of the high-risk individuals had been tested for it. Of those tested, 94% (95% CI=87-100%) were diagnosed with OSA. Treatment with positive airway pressure was prescribed for 82% (95% CI=65-99%) of participants with an OSA diagnosis. CONCLUSIONS Evidence from this nationally representative sample of community-dwelling Medicare beneficiaries suggests that high OSA risk is common but seldom investigated. When investigated, OSA is almost always confirmed and usually treated. These findings suggest a significant gap in OSA assessment for older Americans that could have public health implications.
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Zahuranec DB, Skolarus LE, Burke JF. Author response: Activity limitations and subjective well-being after stroke. Neurology 2018; 90:342. [DOI: 10.1212/wnl.0000000000004955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Burke JF, Feng C, Skolarus LE. Abstract 191: Divergent Short-Term Post-Stroke Outcomes for African Americans Post-Stroke: Lower Mortality, but Greater Disability. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
African Americans (AAs) have more post-stroke disability than non-Hispanic whites (NHWs). Little is known about when this difference emerges. We explored whether this difference exists at the time of post-acute care initiation.
Methods:
Medicare fee-for-service beneficiaries hospitalized from 2010-2014 with a primary stroke diagnosis (ICD-9-CM 431, 433.x1, 434.x1, 436) were identified. We first estimated adjusted and unadjusted proportions of inpatient mortality/hospice discharge, by race. Of survivors, initial post-stroke function was measured by linking Medicare functional assessment files for Inpatient Rehabilitation (IRF), Skilled Nursing (SNF) and Home Health (HHA). Each assessment file contains measures of initial function based on the Functional Independence Measure (FIM). Cross-walks were applied to the SNF and HHA assessments to generate a FIM-based score for these settings (Pseudo-FIM) using 6 motor FIM items scored 0-7 for a total 6-42 point scale (higher is better). Initial motor FIM/Pseudo-FIM was estimated across all 3 settings and in each setting by race. Adjusted analyses accounted for demographics, ICH, comorbidities, tPA and hospital effects using multi-level regression with random hospital intercepts.
Results:
435,371 NHW and 66,707 AA stroke patients were identified. 10.2% of AAs and 14.5% of NHWs (p < 0.001) died or were discharged to hospice, a difference that attenuated slightly after adjustment. Across all settings, AAs had a lower unadjusted motor FIM than NHWs (28.6 vs. 30.5, difference = -1.9, p < 0.001), that attenuated slightly after adjustment (difference -1.7, p < 0.001). Similar unadjusted findings were present across all individual settings for AAs vs. NHWs: IRF (29.8 vs. 31.6, diff = -1.8, p < 0.001), SNF (21.0 vs. 24.7, diff=-3.7, p < 0.001), HHA (33.8 vs. 36.0, diff = -2.2, p < 0.001). Trends were minimally altered by adjustment.
Conclusions:
Mortality and disability immediately after stroke hospitalization diverge by race. Compared to NHWs, AAs have lower early mortality, bit worse motor function across rehab settings. These data suggest that racial differences in patient treatment preferences surrounding mortality-disability trade-offs may exist.
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Callaghan BC, Burke JF, Kerber KA, Skolarus LE, Ney JP, Magliocco B, Esper GJ. The association of neurologists with headache health care utilization and costs. Neurology 2018; 90:e525-e533. [PMID: 29321226 DOI: 10.1212/wnl.0000000000004925] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association of a neurologist visit with headache health care utilization and costs. METHODS Utilizing a large privately insured health care claims database, we identified patients with an incident headache diagnosis (ICD-9 codes 339.xx, 784.0x, 306.81) with at least 5 years follow-up. Patients with a subsequent neurologist visit were matched to controls without a neurologist visit using propensity score matching, accounting for 54 potential confounders and regional variation in neurologist density. Co-primary outcomes were emergency department (ED) visits and hospitalizations for headache. Secondary outcomes were quality measures (abortive, prophylactic, and opioid prescriptions) and costs (total, headache-related, and non-headache-related). Generalized estimating equations assessed differences in longitudinal outcomes between cases and controls. RESULTS We identified 28,585 cases and 57,170 controls. ED visits did not differ between cases and controls (p = 0.05). Hospitalizations were more common in cases in year 0-1 (0.2%, 95% confidence interval [CI] 0.2%-0.3% vs 0.01%, 95% CI 0.01%-0.02%; p < 0.01), with minimal differences in subsequent years. Costs (including non-headache-related costs) and high-quality and low-quality medication utilization were higher in cases in the first year and decreased toward control costs in subsequent years with small differences persisting over 5 years. Opioid prescriptions increased over time in both cases and controls. CONCLUSION Compared with those without a neurologist, headache patients who visit neurologists had a transient increase in hospitalizations, but the same ED utilization. Confounding by severity is the most likely explanation given the non-headache-related cost trajectory. Claims-based risk adjustment will likely underestimate disease severity of headache patients seen by neurologists.
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Stamm BJ, Lineback CM, Skolarus LE, Morgenstern LB, Shah GV. Artery of Percheron Infarct: 12 Cases and Their Complex Clinical Courses. Neurohospitalist 2017; 8:141-145. [PMID: 29977445 DOI: 10.1177/1941874417748543] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Strokes involving the artery of Percheron (AOP), an anatomic variant of thalamic vascular supply, are rare. Little is known about the inpatient hospital course for these patients. We retrospectively identified consecutive patients with AOP in their medical charts from a university-based tertiary care hospital from January 1, 2000, to August 15, 2017. A chart review identified demographics, transfer status, in-hospital versus community onset of stroke, emergency medical services (EMS) use, presenting signs/symptoms, time to radiologic diagnosis (from time of presentation to tertiary care hospital or from time of initial symptom onset in an already hospitalized patient), tissue plasminogen activator (tPA) use, intensive care unit (ICU) stays, intubation, length of stay (LOS), and discharge location. After radiologic inclusion/exclusion criteria were applied, 12 patients were included in the study. There were 7 men and 5 women, and the mean age (SD) was 68 (15). Seven were transfers, and 4 had an in-hospital stroke. Of the 8 community-onset strokes, 7 utilized EMS. Mental status changes occurred in 11 of 12 and ocular disturbances in all patients. Time to radiologic diagnosis averaged 1.9 (median = 1.1) days. One patient received tPA. Eight received care in the ICU. Four were intubated. Average LOS was 8.3 days. Four were discharged home, 3 entered inpatient rehabilitation facilities, and 5 entered skilled nursing facilities. In-hospital stroke status further complicates the already challenging diagnosis of AOP infarct, and clinicians must maintain a high suspicion for this rare stroke in order to quickly diagnose and intervene.
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Lisabeth LD, Baek J, Morgenstern LB, Zahuranec DB, Case E, Skolarus LE. Prognosis of Midlife Stroke. J Stroke Cerebrovasc Dis 2017; 27:1153-1159. [PMID: 29284570 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/14/2017] [Accepted: 11/22/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To characterize stroke outcomes in a midlife population-based stroke cohort, and to describe comorbidities, quality of care, and risk of recurrence in this age group. MATERIALS AND METHODS Ischemic strokes (ISs) were identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2000-2012). Data were from medical records and patient interviews. Ninety-day outcomes (functional, neurologic, cognitive, quality of life [QOL]), prevalence of comorbidities, quality of care, and 1-year recurrence were estimated for those aged 45-64 (midlife) and compared with those aged ≥65 using sex and race-ethnicity adjusted regression models. RESULTS Of 4858 ISs, 33% occurred in midlife. On average, the midlife group reported some difficulty with function, favorable neurologic and cognitive outcomes, and moderate QOL scores at 90 days. All outcomes except QOL were better in the midlife group. Prevalent comorbidities in midlife were hypertension (74%), diabetes (51%), hyperlipidemia (34%), heart disease (26%), prior stroke/transient ischemic attack (23%), smoking 37%, excess alcohol 10%, and atrial fibrillation 4%. Median body mass index (BMI) was 30 (interquartile range: 26-35). Diabetes, smoking, and alcohol were more prevalent and BMI higher in the midlife group. Quality of stroke care did not differ by age. One-year recurrence in midlife was 8% (95% confidence interval: 6%-9%) and did not differ by age. CONCLUSION While 90-day outcomes were more favorable than in the elderly, midlife stroke survivors faced some disability and did not experience better QOL despite better outcomes. Additional research should identify targets to optimize secondary stroke prevention and improve outcomes in midlife stroke survivors-an understudied group with great potential disability and economic impact.
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Kelly KM, Holt KT, Neshewat GM, Skolarus LE. Community Interventions to Increase Stroke Preparedness and Acute Stroke Treatment Rates. Curr Atheroscler Rep 2017; 19:64. [PMID: 29147858 DOI: 10.1007/s11883-017-0695-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW Acute stroke treatments reduce the risk of post-stroke disability. These treatments, tissue plasminogen activator (tPA) and intra-arterial treatment, are highly time-dependent; thus, one of the main barriers to treatment is pre-hospital delay. Stroke preparedness is defined as the ability to recognize stroke symptoms and the intent to activate emergency medical services (EMS). This review describes types of acute stroke treatment and preparedness interventions, including recent mass media interventions to increase acute stroke treatment rates, and adult and youth community interventions to increase stroke preparedness. RECENT FINDINGS The mass media campaigns show mixed results regarding acute stroke treatment rates, possibly attributed to the various media platforms utilized and resources available. The adult and youth community interventions reveal an overall increase in stroke symptom recognition and behavioral intent to call EMS. However, most of these community interventions were not grounded in health behavior theory, and they were tested in single group, pre-post test study designs that assessed behavioral rather than clinical outcomes. The delivery of stroke preparedness information by youth to adults, for example via home assignments, is a promising and innovative approach to stroke preparedness. Mass media and community interventions show promise to increase stroke preparedness and acute stroke treatment rates. The development of health behavior theory-based interventions that are tested via scientifically rigorous study designs are needed to prioritize which interventions should be disseminated to culturally and socially similar communities.
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Skolarus LE, Feng C, Burke JF. No Racial Difference in Rehabilitation Therapy Across All Post-Acute Care Settings in the Year Following a Stroke. Stroke 2017; 48:3329-3335. [PMID: 29089456 DOI: 10.1161/strokeaha.117.017290] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/07/2017] [Accepted: 09/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Black stroke survivors experience greater poststroke disability than whites. Differences in post-acute rehabilitation may contribute to this disparity. Therefore, we estimated racial differences in rehabilitation therapy utilization, intensity, and the number of post-acute care settings in the first year after a stroke. METHODS We used national Medicare data to study 186 168 elderly black and white patients hospitalized with a primary diagnosis of stroke in 2011. We tabulated the proportion of stroke survivors receiving physical, occupational, and speech and language therapy in each post-acute care setting (inpatient rehabilitation facility, skilled nursing facility, and home health agency), minutes of therapy, and number of transitions between settings. We then used generalized linear models to determine whether racial differences in minutes of physical therapy were influenced by demographics, comorbidities, thrombolysis, and markers of stroke severity. RESULTS Black stroke patients were more likely to receive each type of therapy than white stroke patients. Compared with white stroke patients, black stroke patients received more minutes of physical therapy (897.8 versus 743.4; P<0.01), occupational therapy (752.7 versus 648.9; P<0.01), and speech and language therapy (865.7 versus 658.1; P<0.01). There were no clinically significant differences in physical therapy minutes after adjustment. Blacks had more transitions (median, 3; interquartile range, 1-5) than whites (median, 2; interquartile range, 1-5; P<0.01). CONCLUSIONS There are no clinically significant racial differences in rehabilitation therapy utilization or intensity after accounting for patient characteristics. It is unlikely that differences in rehabilitation utilization or intensity are important contributors to racial disparities in poststroke disability.
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Zahuranec DB, Skolarus LE, Feng C, Freedman VA, Burke JF. Activity limitations and subjective well-being after stroke. Neurology 2017; 89:944-950. [PMID: 28733341 PMCID: PMC5577967 DOI: 10.1212/wnl.0000000000004286] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 06/06/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE As limitations in activities of daily living are major components of many stroke outcome scales, we examined how well activity limitations predicted subjective well-being among stroke survivors in a nationally representative survey. METHODS Individuals with a self-reported history of stroke were identified from the National Health and Aging Trends Study. Subjective well-being (primary outcome) was assessed with a validated 7-item measure (higher = greater well-being) assessing emotions (cheerful, bored, full of life, and upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the receipt of help in any of 11 activities of daily living/instrumental activities of daily living. Multivariable linear regression assessed predictors of well-being including medical, physical, cognitive, psychological, and environmental factors. RESULTS A total of 738 stroke survivors age 65 or older were included (57% female, 9% African American, 6% Hispanic). Activity limitations were modestly associated with well-being after adjusting for demographic characteristics and availability of assistance (estimate -0.49, 95% confidence interval -0.61 to -0.37). However, in the fully adjusted model (R2 = 0.28), neither activity limitations nor physical capacity was associated with subjective well-being. Predictors of lower well-being in the final model included depressive symptoms, chewing/swallowing problems, pain that limited activity, and restricted participation in valued life activities. Income and executive function were modestly associated with improved well-being, while comorbidities and communication technology access were not associated. CONCLUSIONS Activity limitations were not associated with stroke survivors' subjective well-being after adjustment for other factors. While some predictors of well-being after stroke were identified, the determinants of well-being remained largely unexplained.
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Sharrief AZ, Sánchez BN, Lisabeth LD, Skolarus LE, Zahuranec DB, Baek J, Garcia N, Case E, Morgenstern LB. The Impact of Pre-Stroke Depressive Symptoms, Fatalism, and Social Support on Disability after Stroke. J Stroke Cerebrovasc Dis 2017; 26:2686-2691. [PMID: 28774795 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/01/2017] [Accepted: 06/25/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Psychological and social factors have been linked to stroke mortality; however, their impact on stroke disability is unclear. The purpose of this study was to evaluate the impact of pre-stroke fatalism, depressive symptoms, and social support on 90-day neurologic, functional, and cognitive outcomes. METHODS Ischemic strokes (2008-2011) were identified from the Brain Attack Surveillance in Corpus Christi Project. Validated scales were used to assess fatalism, depressive symptoms, and social support during baseline interviews. The National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living (ADL/IADL) scale, and Modified Mini-Mental State Exam (3MSE) were used to assess 90-day outcomes. The associations between the pre-stroke variables and 90-day outcomes were estimated from regression models adjusting for demographics, risk factors, tissue-type plasminogen activator treatment, and comorbidities. RESULTS Among 364 stroke survivors, higher pre-stroke fatalism was associated with worse functional (.17 point higher ADL/IADL per interquartile range [IQR] higher fatalism; 95% confidence interval [CI]: .05, .30) and cognitive (2.81 point lower 3MSE per IQR higher fatalism; 95% CI: .95, 4.67) outcomes. Higher pre-stroke depressive symptoms were associated with worse functional (.16 point higher ADL/IADL per IQR higher Patient Health Questionnaire-9; 95% CI: .04, .28) and cognitive (2.28 point lower 3MSE per IQR higher Patient Health Questionnaire-9; 95% CI: .46, 4.10) outcomes. Participants in the middle tertile of social support had better cognitive outcomes (3.75 points higher 3MSE; 95% CI: .93, 6.56) compared with the highest tertile. CONCLUSIONS The associations between pre-stroke fatalism, depressive symptoms, and social support and 90-day outcomes suggest that psychosocial factors play an important role in stroke recovery.
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Skolarus LE, Cowdery J, Dome M, Bailey S, Baek J, Byrd JB, Hartley SE, Valley SC, Saberi S, Wheeler NC, McDermott M, Hughes R, Shanmugasundaram K, Morgenstern LB, Brown DL. Reach Out Churches: A Community-Based Participatory Research Pilot Trial to Assess the Feasibility of a Mobile Health Technology Intervention to Reduce Blood Pressure Among African Americans. Health Promot Pract 2017; 19:495-505. [PMID: 28583024 DOI: 10.1177/1524839917710893] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Innovative strategies are needed to reduce the hypertension epidemic among African Americans. Reach Out was a faith-collaborative, mobile health, randomized, pilot intervention trial of four mobile health components to reduce high blood pressure (BP) compared to usual care. It was designed and tested within a community-based participatory research framework among African Americans recruited and randomized from churches in Flint, Michigan. The purpose of this pilot study was to assess the feasibility of the Reach Out processes. Feasibility was assessed by willingness to consent (acceptance of randomization), proportion of weeks participants texted their BP readings (intervention use), number lost to follow-up (retention), and responses to postintervention surveys and focus groups (acceptance of intervention). Of the 425 church members who underwent BP screening, 94 enrolled in the study and 73 (78%) completed the 6-month outcome assessment. Median age was 58 years, and 79% were women. Participants responded with their BPs on an average of 13.7 (SD = 10.7) weeks out of 26 weeks that the BP prompts were sent. All participants reported satisfaction with the intervention. Reach Out, a faith-collaborative, mobile health intervention was feasible. Further study of the efficacy of the intervention and additional mobile health strategies should be considered.
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Dunietz GL, Braley TJ, Chervin RD, Burke JF, Feng C, Skolarus LE, Lisabeth LD. 0462 RECOGNITION AND TREATMENT OF OBSTRUCTIVE SLEEP APNEA AMONG MEDICARE BENEFICIARIES. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Skolarus LE, Mazor KM, Sánchez BN, Dome M, Biller J, Morgenstern LB. Development and Validation of a Bilingual Stroke Preparedness Assessment Instrument. Stroke 2017; 48:1020-1025. [PMID: 28250199 DOI: 10.1161/strokeaha.116.015107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/19/2016] [Accepted: 01/09/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke preparedness interventions are limited by the lack of psychometrically sound intermediate end points. We sought to develop and assess the reliability and validity of the video-Stroke Action Test (video-STAT) an English and a Spanish video-based test to assess people's ability to recognize and react to stroke signs. METHODS Video-STAT development and testing was divided into 4 phases: (1) video development and community-generated response options, (2) pilot testing in community health centers, (3) administration in a national sample, bilingual sample, and neurologist sample, and (4) administration before and after a stroke preparedness intervention. RESULTS The final version of the video-STAT included 8 videos: 4 acute stroke/emergency, 2 prior stroke/nonemergency, 1 nonstroke/emergency, and 1 nonstroke/nonemergency. Acute stroke recognition and action response were queried after each vignette. Video-STAT scoring was based on the acute stroke vignettes only (score range 0-12 best). The national sample consisted of 598 participants, 438 who took the video-STAT in English and 160 who took the video-STAT in Spanish. There was adequate internal consistency (Cronbach α=0.72). The average video-STAT score was 5.6 (SD=3.6), whereas the average neurologist score was 11.4 (SD=1.3). There was no difference in video-STAT scores between the 116 bilingual video-STAT participants who took the video-STAT in English or Spanish. Compared with baseline scores, the video-STAT scores increased after a stroke preparedness intervention (6.2 versus 8.9, P<0.01) among a sample of 101 black adults and youth. CONCLUSIONS The video-STAT yields reliable scores that seem to be valid measures of stroke preparedness.
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Skolarus LE, Freedman VA, Feng C, Burke JF. African American Stroke Survivors: More Caregiving Time, but Less Caregiving Burden. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003160. [PMID: 28228451 DOI: 10.1161/circoutcomes.116.003160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Blacks have higher stroke incidence and experience greater poststroke disability than whites. To optimize care for stroke survivors, it is important to understand the amount of care that they receive and the implications for stroke caregivers. METHODS AND RESULTS Data from 2 nationally representative, population-based studies, the NHATS (National Health and Aging Trends Study) linked to the NSOC (National Study of Caregiving), were used to identify elderly stroke survivors and their caregivers. We compared hours of care received and unmet activity need among the 581 white and 225 black stroke survivors. We then performed racial comparisons of positive and negative aspects of caregiving reported by caregivers of black and white stroke survivors. Black stroke survivors were more likely than white stroke survivors to have a caregiver (62.5% versus 49.7%; P<0.01) and received on average more hours of help per week (31.7 versus 20.5; P<0.01). There was little racial difference in unmet need for assistance. Caregivers of black stroke survivors reported more positive aspects of caregiving than caregivers of white stroke survivors (6.8 versus 6.0; P<0.01). There was no racial difference in negative aspects of caregiving, depression, or anxiety. CONCLUSIONS Black stroke survivors received an average of ≈11 more hours of care than white stroke survivors without substantial differences in unmet need. Despite providing more hours of care, caregivers of black stroke were more positive about their caregiver role than caregivers of white stroke survivors.
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Terman SW, Burke JF, Skolarus LE. Abstract 163: Early Outpatient Followup Associated With Lower Readmission Among Medicare Patients With Ischemic Stroke. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Reducing hospital readmission is an important target for reducing morbidity and cost in acute ischemic stroke. However, strategies to reduce readmissions are lacking. We examined the association between time to first outpatient contact and readmission to inform interventions to optimize the inpatient-outpatient transition.
Methods:
We performed a retrospective cohort study of all Medicare fee-for-service patients discharged home after an acute ischemic stroke in 2012. Stroke hospitalizations were identified with ICD-9-CM codes 433.x1, 434.x1 and 436. Our primary explanatory variable was whether patients had a primary care or neurology visit within 30 days of discharge. Our primary outcome variable was all-cause 30-day hospital readmission. This relationship was evaluated using mixed-effects logistic regressions adjusted for patient demographics and comorbidities, hospital quality of care (using Hospital Compare data), stroke volume, regional socioeconomic (SES) variables and a random hospital-level intercept. Secondary analyses explored timing of follow-up, provider continuity, combined provider effects, follow-up-SES interactions and time-to-event analyses.
Results:
The cohort included 69,981 Medicare beneficiaries with acute ischemic stroke. A primary care physician (OR 0.82, 95% CI 0.77-0.86) or neurologist (OR 0.84, 95% CI 0.78-0.91) visit within 30 days of discharge were associated with decreased odds of readmission. On secondary analyses, return visits within 15 days were associated with further reductions in the odds of readmission for primary care (OR 0.79, 95% 0.75-0.84), but not for neurology follow-up (OR 0.94, 95% 0.85-1.05). The primary findings differed minimally when adjusting for provider effects simultaneously, accounting for provider-SES interactions or in time-to-event analyses.
Conclusion:
Early outpatient follow-up was associated with a lower odds of hospital readmission among elderly stroke patients who are discharged from the hospital to home. Our data suggest that outpatient care may be crucial in reducing preventable hospital readmissions and identifies a potentially important target for future interventions aimed at reducing the cost and burden of stroke.
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Towfighi A, Ovbiagele B, El Husseini N, Hackett ML, Jorge RE, Kissela BM, Mitchell PH, Skolarus LE, Whooley MA, Williams LS. Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 48:e30-e43. [PMID: 27932603 DOI: 10.1161/str.0000000000000113] [Citation(s) in RCA: 354] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.
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