Stroke Performance Measures Do Not Predict Functional Outcome

BACKGROUND AND PURPOSE

Poststroke functional outcome is critical to stroke survivors. We sought to determine whether adherence to current stroke performance measures is associated with better functional outcome 90 days after an ischemic stroke.

METHODS

Utilizing the Brain Attack Surveillance in Corpus Christi cohort, we examined adherence to 7 ischemic stroke performance measures from February 2009 to June 2012. Adherence to the measures was analyzed in aggregate using a binary defect-free score and an opportunity score, representing the proportion of eligible measures met. The opportunity score ranges from 0 to 1, with values closer to 1 implying better adherence. Functional outcome, defined by an activities of daily living and instrumental activities of daily living (ADL/IADL) score (range 1-4, higher scores worse), was ascertained at 90 days poststroke. Tobit regression models were fitted to examine the associations between the performance measures and functional outcome, adjusting for demographic and clinical characteristics, including stroke severity.

RESULTS

There were 565 patients with ischemic stroke included in the analysis. The median ADL/IADL score was 2.32 (interquartile range [IQR]: 1.41-3.41). The median opportunity score was 1 (IQR: 0.8-1), and 58.4% of the patients received defect-free care. After adjustment, the opportunity score (P = .67) and defect-free care (P = .92) were not associated with functional outcome.

CONCLUSION

In this population, adherence to a composite of current stroke performance measures was not associated with poststroke functional outcome after adjustment for other factors. Performance measures that are associated with improved functional outcome should be developed and incorporated into stroke quality measures.

Moving Toward an Understanding of Disability in Older U.S. Stroke Survivors

OBJECTIVES

We test a comprehensive model of disability in older stroke survivors and determine the relative contribution of neighborhood, economic, psychological, and medical factors to disability.

METHOD

The sample consisted of 728 stroke survivors from the National Health and Aging Trends Study (NHATS), who were 65 years and older living in community settings or residential care. Confirmatory factor analysis and structural equation modeling were used to test relationships between neighborhood, socioeconomic, psychological, and medical factors, and disability.

RESULTS

Economic and medical context were associated with disability directly and indirectly through physical impairment. Neighborhood context was associated with disability, but was only marginally statistically significant ( p = .05). The effect of economic and neighborhood factors was small compared with that of medical factors.

DISCUSSION

Neighborhood and economic factors account for a portion of the variance in disability among older stroke survivors beyond that of medical factors.

Care Received by Elderly US Stroke Survivors May Be Underestimated

BACKGROUND AND PURPOSE

Previous studies exploring stroke-related caregiving focused solely on informal caregiving and a relatively limited set of activities. We sought to determine whether, and at what cost, stroke survivors receive more care than matched controls using an expanded definition of caregiving and inclusion of paid caregivers.

METHODS

Data were drawn from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. NHATS personnel conducted in-person interviews with respondents or proxies to determine the weekly hours of care received. We compared hours of assistance received between self-reported stroke survivors (n=892) and demography- and comorbidity-matched nonstroke controls (n=892). The annual cost of stroke caregiving was estimated using reported paid caregiving data and estimates of unpaid caregiving costs.

RESULTS

Of community-dwelling elderly stroke survivors, 51.4% received help from a caregiver. Stroke survivors received an average of 10 hours of additional care per week compared with demography- and comorbidity-matched controls (22.3 hours versus 11.8 hours; P<0.01). We estimate that the average annual cost for caregiving for an elderly stroke survivor is ≈$11 300 or ≈$40 billion annually, for all elderly stroke survivors, of which $5000 per person, or $18.2 billion annually, is specific to stroke.

CONCLUSIONS

Although stroke survivors are known to require considerable caregiving resources, our findings suggest that previous assessments may underestimate hours of care received and hence costs.

The Association between Changes in Behavioral Risk Factors for Stroke and Changes in Blood Pressure

BACKGROUND

High blood pressure (BP) is the leading risk factor for stroke. Data on the association of physical activity (PA), fruit and vegetable (F&V) consumption, and dietary sodium with hypertension are lacking in Hispanic communities. In the current report, we provide data on the association between changes in these stroke behavioral risk factors and BP change.

METHODS

Participants were recruited from participating Catholic churches in Nueces County, Texas. BP was measured, and self-reported validated scales of F&V consumption, dietary sodium, and PA were collected at baseline and at 12 months. Linear mixed models were used to examine the associations between tertiles of improvement in the 3 behavior outcomes and BP change, adjusted for demographic characteristics. The association between the binary measure of at least 5 mmHg diastolic blood pressure (DBP) or 10 mmHg systolic blood pressure (SBP) reduction and behavior change was estimated with multilevel logistic regression models.

RESULTS

Of 586 participants, 66% were female and 82% were Mexican American (MA), and the mean age was 54 years. High compared with low change in PA was significantly associated with DBP change (P = .022), and high compared with low change in F&V intake was significantly associated with SBP change (P = .032). For the binary changes in DBP or SBP, there was a borderline association of PA (P = .054); all other variables were not associated (P > .10).

CONCLUSIONS

PA and F&V consumption are potential stroke prevention targets in predominantly MA populations.

Stroke Ready Intervention: Community Engagement to Decrease Prehospital Delay

BACKGROUND

Time-limited acute stroke treatments are underused, primarily due to prehospital delay. One approach to decreasing prehospital delay is to increase stroke preparedness, the ability to recognize stroke, and the intention to immediately call emergency medical services, through community engagement with high-risk communities.

METHODS AND RESULTS

Our community-academic partnership developed and tested "Stroke Ready," a peer-led, workshop-based, health behavior intervention to increase stroke preparedness among African American youth and adults in Flint, Michigan. Outcomes were measured with a series of 9 stroke and nonstroke 1-minute video vignettes; after each video, participants selected their intended response (primary outcome) and symptom recognition (secondary outcome), receiving 1 point for each appropriate stroke response and recognition. We assessed differences between baseline and posttest appropriate stroke response, which was defined as intent to call 911 for stroke vignettes and not calling 911 for nonstroke, nonemergent vignettes and recognition of stroke. Outcomes assessments were performed before workshop 1 (baseline), at the conclusion of workshop 2 (immediate post-test), and 1 month later (delayed post-test). A total of 101 participants completed the baseline assessment (73 adults and 28 youths), 64 completed the immediate post-test, and 68 the delayed post-test. All participants were African American. The median age of adults was 56 (interquartile range 35-65) and of youth was 14 (interquartile range 11-16), 65% of adults were women, and 50% of youths were women. Compared to baseline, appropriate stroke response was improved in the immediate post-test (4.4 versus 5.2, P<0.01) and was sustained in the delayed post-test (4.4 versus 5.2, P<0.01). Stroke recognition did not change in the immediate post-test (5.9 versus 6.0, P=0.34), but increased in the delayed post-test (5.9 versus 6.2, P=0.04).

CONCLUSIONS

Stroke Ready increased stroke preparedness, a necessary step toward increasing acute stroke treatment rates.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01499173.

Mexican Americans are Less Likely to Return to Work Following Stroke: Clinical and Policy Implications

BACKGROUND

Greater poststroke disability and U.S. employment policies may disadvantage minority stroke survivors from returning to work. We explored ethnic differences in return to work among Mexican Americans (MAs) and non-Hispanic whites (NHWs) working at the time of their stroke.

METHODS

Stroke patients were identified from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) study from August 2011 to December 2013. Employment status was obtained at baseline and 90-day interviews. Sequential logistic regression models were built to assess ethnic differences in return to work after accounting for the following: (1) age (<65 versus ≥65); (2) sex; (3) 90-day National Institutes of Health Stroke Scale (NIHSS); and (4) education (lower than high school versus high school or higher).

RESULTS

Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke, of which 125 (63%) completed the 90-day outcome interview. Forty-nine (40%) stroke survivors returned to work by 90 days. MAs were less likely to return to work (OR = .45, 95% CI .22-.94) than NHWs. The ethnic difference became nonsignificant after adjusting for NIHSS (OR = .59, 95% CI .24-1.44) and further attenuated after adjusting for education (OR = .85, 95% CI .32- 2.22).

CONCLUSIONS

The majority of stroke survivors did not return to work within 90 days of their stroke. MA stroke survivors were less likely to return to work after stroke than NHW stroke survivors which was due to their greater neurological deficits and lower educational attainment compared with that of NHW stroke survivors. Future work should focus on clinical and policy efforts to reduce ethnic disparities in return to work.

Medicare Part D payments for neurologist-prescribed drugs

OBJECTIVE

To describe neurologists' Medicare Part D prescribing patterns and the potential effect of generic substitutions and price negotiation, which is currently prohibited.

METHODS

The 2013 Medicare Part D Prescriber Public Use and Summary files were used. Payments for medications were aggregated by provider and drug (brand or generic). Payment, proportion of generic claims or day's supply, and median payment per monthly supply of medication were calculated by physician specialty and drug. Savings from generic substitution were estimated for brand drugs with a generic available. Medicare prices were compared to drug prices negotiated by the federal government with pharmaceutical manufacturers for the Veterans Administration (VA).

RESULTS

Neurologists comprised 13,060 (1.2%) providers with $5.0 billion (4.8%) in total payments, third highest of all specialties, with a median monthly payment of $141 (interquartile range $85-225). Multiple sclerosis drugs had the highest payments ($1.8 billion). Within neurologic disease groups ($3.4 billion in payments), 54.2%-91.8% of monthly supplies were generic, but 11.9%-71.3% of the payment was for generic medications. Generic substitution resulted in a $269 million (6.5%) payment decrease. VA pricing resulted in $1.5 billion (44.5% of $3.4 billion) in savings.

CONCLUSIONS

High payment per monthly supply of medication underlies the high total neurology drug payments and is driven by multiple sclerosis drugs. Lowering drug expenditures by Medicare should focus on drug prices.

Abstract 187: Are Limitations in Activities of Daily Living the Best Predictor of Well-Being After Stroke?

Objective: Limitations in activities of daily living are major components of most stroke outcome scales. We examined whether activity limitations or other factors predicted self-reported well-being among stroke survivors in a large nationally representative survey.

Methods: Individuals with a self-reported history of stroke were identified from the National Health and Aging Tends Study (NHATS wave 1, year 2011). Self-reported well-being (primary outcome) was defined based on a previously validated 7-item measure (higher=greater well-being) assessing emotions (feeling cheerful, bored, full of life, or upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the need for assistance in any of 11 activities of daily living/instrumental activities of daily living (ADLS/IADLS). Multivariable linear regression was used to identify factors associated with well-being.

Results: 738 stroke survivors 65 or older were included (57% female, 9% African American, 6% Hispanic). The final multivariable model (see Table) only modestly explained the total variability in well-being (R-squared=0.28). Number of ADL/IADL limitations was not associated with well being. Notable predictors of lower well being included depressive symptoms, chewing problems, pain that limited activity, and restricted ability to participate in valued life activities. Income was modestly associated with improved well-being, while social network support and access to communication technology were not associated.

Conclusions: Limitations in ADLs/IADLs were not predictive of well-being in this population of stroke survivors, which raises the question of whether existing outcome scales adequately measure the most important patient-centered outcomes. Much of what determines well-being among stroke survivors remains unexplained.

Abstract 181: A Systematic Review of Interventions to Increase tPA Administration

Introduction: Rates of tPA administration remain low nationally and globally despite its demonstrated efficacy. We performed a systematic review and meta-analysis of interventions to increase the rate of tPA administration.

Methods: We searched PubMed and EMBASE to identify all studies (excluding case reports) published between 1995 and January 8, 2015 documenting interventions to increase the utilization of tPA. We screened each study with pre-specified inclusion and exclusion criteria. Design elements and study data were extracted from eligible studies. The principal summary measure was the percentage change in rate of tPA administration. Fixed and random effects meta-analytic models were built to summarize the effect of intervention compared to control as well as intervention subtypes.

Results: Our search yielded 1457 results of which 25 met eligibility criteria. We identified 13 pre-post studies and 11 randomized or quasi-experimental studies. Included studies utilized EMS (n=14), telemedicine (n=6), and public education (n=5). Intervention settings included urban (n=13), rural (n=4), and combined (n=4). In a fixed effect model, tPA administration was significantly higher in the intervention arm across all studies that limited enrollment to ischemic stroke patients (n=14) with a risk ratio (RR) of 1.71. Interventions involving EMS were associated with an increased rate of tPA administration with a RR of 1.51, (95% CI: 1.43-1.59, p<0.0001); promoting public education RR = 2.62, (95% CI: 1.54-4.43, p<0.01); and utilizing telemedicine RR = 2.97, (95% CI: 2.61-3.39, p<0.0001).

Conclusions: Interventions to increase tPA use appear to have considerable efficacy. Comparative inferences between intervention types are limited by small sample size and intervention heterogeneity.

Differences Between US and UK Adults in Stroke Preparedness: Evidence From Parallel Population-Based Community Surveys

BACKGROUND AND PURPOSE

Although time-dependent treatment is available, most people delay contacting emergency medical services for stroke. Given differences in the healthcare system and public health campaigns, exploring between-country differences in stroke preparedness may identify novel ways to increase acute stroke treatment.

METHODS

A survey was mailed to population-based samples in Ingham County, Michigan, US (n=2500), and Newcastle upon Tyne, UK (n=2500). Surveys included stroke perceptions and stroke/nonstroke scenarios to assess recognition and response to stroke. Between-country differences and associations with stroke preparedness were examined using t tests and linear mixed models.

RESULTS

Overall response rate was 27.4%. The mean age of participants was 55 years, and 58% were female. US participants were better in recognizing stroke (70% versus 63%, d=0.27) and were more likely to call emergency medical services (55% versus 52%, d=0.11). After controlling for demographics and comorbidities, US participants remained more likely to recognize stroke but were not more likely to respond appropriately. A greater belief that medical treatment can help with stroke and understanding of stroke was associated with improved stroke recognition and response.

CONCLUSIONS

Overall, stroke recognition and response were moderate. US participants were modestly better at recognizing stroke, although there was little difference in response to stroke. Future stroke awareness interventions could focus more on stroke outcome expectations and developing a greater understanding of stroke among the public.

Protocol Deviations before and after Treatment with Intravenous Tissue Plasminogen Activator in Community Hospitals

BACKGROUND

Protocol deviations before and after tissue plasminogen activator (tPA) treatment for ischemic stroke are common. It is unclear if patient or hospital factors predict protocol deviations. We examined predictors of protocol deviations and the effects of protocol violations on symptomatic intracerebral hemorrhage (sICH).

METHODS

We used data from the Increasing Stroke Treatment through Interventional Behavior Change Tactics trial, a cluster-randomized, controlled trial evaluating the efficacy of a barrier assessment and educational intervention to increase appropriate tPA use in 24 Michigan community hospitals, to review tPA treatments between 2007 and 2010. Protocol violations were defined as deviations from the standard tPA protocol, both before and after treatment. Multilevel logistic regression models were fitted to determine if patient and hospital variables were associated with pretreatment or post-treatment protocol deviations.

RESULTS

During the study, 557 patients (mean age 70, 52% male, median National Institutes of Health Stroke Scale score 12) were treated with tPA. Protocol deviations occurred in 233 (42%) patients: 16% had pretreatment deviations, 35% had post-treatment deviations, and 9% had both. The most common protocol deviations included elevated post-treatment blood pressure, antithrombotic agent use within 24 hours of treatment, and elevated pretreatment blood pressure. Protocol deviations were not associated with sICH, stroke severity, or hospital factors. Older age was associated with pretreatment protocol deviations (adjusted odds ratio [OR], .52; 95% confidence interval [CI], .30-.92). Pretreatment deviations were associated with post-treatment deviations (adjusted OR, 3.20; 95% CI, 1.91-5.35).

CONCLUSIONS

Protocol deviations were not associated with sICH. Aside from age, patient and hospital factors were not associated with protocol deviations.

Neurology Choosing Wisely recommendations: 74 and growing

To increase neurologist awareness and inform future efficiency efforts, we identified all neurology-related Choosing Wisely items. Items were categorized by neurologic specialty, disease/symptom, and test/treatment. Of 370 items provided by 65 medical societies, 74 (20%) items were relevant to neurologists. Twelve were duplicated by multiple societies. Items pertaining to 10 neurologic subspecialties were identified, but none for movement disorders and neuromuscular disease. While many recommendations question the use of imaging, few address other high-cost neurologic tests such as EMG/nerve conduction studies and EEG. A rapidly growing number of neurology-related Choosing Wisely recommendations exist including areas of consensus and areas with few recommendations despite high costs. Consensus items should be prioritized for near-term interventions, while areas with few recommendations represent opportunities for future research.

A Multicomponent Behavioral Intervention to Reduce Stroke Risk Factor Behaviors: The Stroke Health and Risk Education Cluster-Randomized Controlled Trial

BACKGROUND AND PURPOSE

The Stroke Health and Risk Education Project was a cluster-randomized, faith-based, culturally sensitive, theory-based multicomponent behavioral intervention trial to reduce key stroke risk factor behaviors in Hispanics/Latinos and European Americans.

METHODS

Ten Catholic churches were randomized to intervention or control group. The intervention group received a 1-year multicomponent intervention (with poor adherence) that included self-help materials, tailored newsletters, and motivational interviewing counseling calls. Multilevel modeling, accounting for clustering within subject pairs and parishes, was used to test treatment differences in the average change since baseline (ascertained at 6 and 12 months) in dietary sodium, fruit and vegetable intake, and physical activity, measured using standardized questionnaires. A priori, the trial was considered successful if any one of the 3 outcomes was significant at the 0.05/3 level.

RESULTS

Of 801 subjects who consented, 760 completed baseline data assessments, and of these, 86% completed at least one outcome assessment. The median age was 53 years; 84% subjects were Hispanic/Latino; and 64% subjects were women. The intervention group had a greater increase in fruit and vegetable intake than the control group (0.25 cups per day [95% confidence interval: 0.08, 0.42], P=0.002), a greater decrease in sodium intake (-123.17 mg/d [-194.76, -51.59], P=0.04), but no difference in change in moderate- or greater-intensity physical activity (-27 metabolic equivalent-minutes per week [-526, 471], P=0.56).

CONCLUSIONS

This multicomponent behavioral intervention targeting stroke risk factors in predominantly Hispanics/Latinos was effective in increasing fruit and vegetable intake, reaching its primary end point. The intervention also seemed to lower sodium intake. Church-based health promotions can be successful in primary stroke prevention efforts.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01378780.

Marked Regional Variation in Acute Stroke Treatment Among Medicare Beneficiaries

BACKGROUND AND PURPOSE

Little is known about how regions vary in their use of thrombolysis (intravenous tissue-type plasminogen activator and intra-arterial treatment) for acute stroke. We sought to determine regional variation in thrombolysis treatment and investigate the extent to which regional variation is accounted for by patient demographics, regional factors, and elements of stroke systems of care.

METHODS

Retrospective cross-sectional study of all fee-for-service Medicare patients with ischemic stroke admitted via the Emergency Department from 2007 to 2010 who were assigned to 1 of 3436 hospital service areas. Multilevel logistic regression was used to estimate regional thrombolysis rates, determine the variation in thrombolysis treatment attributable to the region and estimate thrombolysis treatment rates and disability prevented under varied improvement scenarios.

RESULTS

There were 844 241 ischemic stroke admissions of which 3.7% received intravenous tissue-type plasminogen activator and 0.5% received intra-arterial stroke treatment without or without intravenous tissue-type plasminogen activator over the 4-year period. The unadjusted proportion of patients with ischemic stroke who received thrombolysis varied from 9.3% in the highest treatment quintile compared with 0% in the lowest treatment quintile. Measured demographic and stroke system factors were weakly associated with treatment rates. Region accounted for 7% to 8% of the variation in receipt of thrombolysis treatment. If all regions performed at the level of 75th percentile region, ≈7000 additional patients with ischemic stroke would be treated with thrombolysis.

CONCLUSIONS

There is substantial regional variation in thrombolysis treatment. Future studies to determine features of high-performing thrombolysis treatment regions may identify opportunities to improve thrombolysis rates.

Racial Disparities in Poststroke Activity Limitations Are Not due to Differences in Prestroke Activity Limitation

BACKGROUND

African Americans experience greater poststroke disability than whites. We explored whether these differences are because of differences in prestroke function.

METHODS

The Panel Study of Income Dynamics (PSID) is a nationally representative US panel survey of families and their descendants. We included all PSID respondents who reported an incident stroke between 2001 and 2011. Our primary outcome was an index representing the sum of total activities of daily living (ADL) limitations (0-7), and the secondary outcome was an index of instrumental activities of daily living (IADL) limitations (0-6). Survey-weighted descriptive statistics and Poisson regression were used to estimate racial differences in ADL and IADL before, with, and after the wave when incident stroke was reported.

RESULTS

A total of 534 incident strokes were identified, 198 (37%) in African Americans. There were no prestroke racial differences in activity limitations (.7 versus .7, P = .99). In the wave of the incident stroke (between 0 and 2 years from incident stroke), African Americans had considerably more ADL limitations than whites (2.2 versus 1.5, P = .048). These racial differences persisted after adjusting for age, sex, and comorbidities. For IADLs, adjusted models suggested small prestroke racial differences and larger poststroke differences.

CONCLUSIONS

Racial disparities in poststroke ADL limitations are not due to prestroke activity limitations. Instead, differences appear largest in the first 2 years after stroke.

Medicare payments to the neurology workforce in 2012

OBJECTIVE

Little is known about how neurology payments vary by service type (i.e., evaluation and management [E/M] vs tests/treatments) and compare to other specialties, yet this information is necessary to help neurology define its position on proposed payment reform.

METHODS

Medicare Provider Utilization and Payment Data from 2012 were used. These data included all direct payments to providers who care for fee-for-service Medicare recipients. Total payment was determined by medical specialty and for various services (e.g., E/M, EEG, electromyography/nerve conduction studies, polysomnography) within neurology. Payment and proportion of services were then calculated across neurologists' payment categories.

RESULTS

Neurologists comprised 1.5% (12,317) of individual providers who received Medicare payments and were paid $1.15 billion by Medicare in 2012. Sixty percent ($686 million) of the Medicare payment to neurologists was for E/M, which was a lower proportion than primary providers (approximately 85%) and higher than surgical subspecialties (range 9%-51%). The median neurologist received nearly 75% of their payments from E/M. Two-thirds of neurologists received 60% or more of their payment from E/M services and over 20% received all of their payment from E/M services. Neurologists in the highest payment category performed more services, of which a lower proportion were E/M, and performed at a facility, compared to neurologists in lower payment categories.

CONCLUSION

E/M is the dominant source of payment to the majority of neurologists and should be prioritized by neurology in payment restructuring efforts.

Abstract T P146: The Impact of Pre-stroke Depressive Symptoms, Fatalism, and Social Support on Disability after Stroke

Background: Fatalism and depression have been linked to post-stroke mortality and stroke recurrence. Our objective was to evaluate the impact of pre-stroke fatalism, depressive symptoms, and social support on neurological, functional, and cognitive outcomes after stroke.

Methods: Ischemic strokes (2008 -2011) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. At baseline interviews, pre-stroke depressive symptoms, fatalism, and social support were assessed using Patient Health Questionnaire (PHQ-9; 0-27; higher worse), modified Mental Adjustment for Stroke and Pearlin scales (8-40; higher worse), and a 7-item social support scale (0 -14; higher better); respectively. Outcome among survivors was assessed at 90 days using the National Institutes of Health Stroke Scale (NIHSS; 0-44, higher worse); activities/ instrumental activities of daily living (ADL/IADL; 1-4, higher worse); and Modified Mini-Mental State Exam (3MSE; 0-100, lower worse). Regression models were used to evaluate associations of interest, adjusting for demographic and clinical factors.

Results: Among 364 participants with outcome interviews and complete covariate data, mean age was 66, 49.5% were female and 58.8% were Mexican American. In adjusted models, higher pre-stroke fatalism (median 17; IQR 12, 20) was associated with poorer functional (0.17 point higher ADL/IADL score per IQR higher fatalism score; 95% CI 0.05, 0.30) and cognitive (2.81 point lower 3MSE per IQR higher fatalism score; 95% CI 0.95, 4.67) outcomes. Similarly, higher pre-stroke depressive symptoms (median 3; IQR 0, 9) were associated with poorer functional (0.16 point higher ADL/IADL per IQR higher PHQ-9; 95% CI .04, 0.28) and cognitive (2.28 point lower 3MSE per IQR higher PHQ-9; 95% CI 0.46, 4.10) outcomes. There were no significant associations between fatalism or depressive symptoms and NIHSS or between social support (median 10; IQR 7, 12) and 90-day outcomes. Conclusions: Among ischemic stroke survivors, pre-stroke fatalism and depressive symptoms, but not social support, impact 90-day functional and cognitive outcomes. These findings reinforce the importance of evaluating and addressing psychological factors in stroke care.

Abstract T P131: Racial Disparities in Post-Stroke Activity Limitations are not due to Pre-Stroke Activity Limitation Differences

Introduction: African Americans have higher stroke incidence and more long-term disability than whites, in spite of similar stroke severity. We sought to explore whether these differences may be due to differences in pre-stroke functioning.

Methods: Initiated in 1968, the Panel Study of Income Dynamics (PSID) is a nationally representative US panel survey of approximately 5,000 families and their descendants, including an oversample of African-American families. We studied all PSID household heads and spouses (about 12,000 individuals per year) who reported they had an incident stroke in the prior two-year period (directly or by proxy response) between 2001-2011. PSID queries difficulty with seven different self-care and mobility activities. Our primary outcome was an index representing the sum of total activity limitations (0-7). Racial differences in activity limitations were estimated using survey-weighted descriptive statistics for study waves before, with and after the wave when incident stroke was reported.

Results: A total of 534 incident strokes were identified, 198 (37%) in African-Americans who were younger (52.2 vs. 60.1, p < 0.001) and had more hypertension (57% vs. 42%, p < 0.01) and diabetes (23% vs. 14%, p < 0.01) than whites. In the wave prior to the stroke there was no racial difference in activity limitations. In the wave of the incident stroke (between 0-2 years from incident stroke), African Americans had considerably more activity limitations than whites, a difference that decreased over subsequent waves. (Figure) These changes persisted after adjusting for age, sex and comorbidities.

Conclusion: Racial disparities in stroke functional outcomes are not due to pre-stroke functional differences and most likely arise after stroke.

Abstract T P296: Race/Ethnicity Disparities in Access to Inpatient Physical and Occupational Therapy Exist

Introduction: African-Americans and Hispanics have worse functional outcomes after stroke, although the reasons for these disparities are not known. As more intense rehabilitation therapy after stroke is associated with improved outcomes, we hypothesized that decreased access to therapy during stroke hospitalization may contribute to outcome disparities.

Methods: The 2008 State Inpatient Databases (SID) for seven states, which include data on all inpatient discharges within a state were used to identify all primary ischemic stroke (ICD-9-CM 433.x1, 434.x1, 436) and intracerebral hemorrhage discharges (435). Receipt of physical (PT) and occupational (OT) therapy was determined using HCUP definitions. Logistic regression was used to compare receipt of therapy by race/ethnicity adjusting for demographics, insurance, comorbidities, stroke type, and presumptive severity markers (length of stay, ICU use, presentation via ED, receipt of IV tPA, use of life-sustaining treatments). Hospital effects were then accounted for by including all risk adjustors in a multi-level model with a random hospital-level intercept.

Results: A total of 472, 210 discharges in 702 hospitals were identified, 59% in whites, 13% in African Americans and 4% in Hispanics; 71% received PT and 47% OT. Before accounting for hospital effects, African-Americans (OR 0.82 for PT, 0.84 for OT) and Hispanics (OR 0.79 for PT, 0.64 for OT) were less likely to receive therapy (p < 0.001 for all comparisons). Hospital was an important predictor of receipt of therapy, intra-class correlation coefficient (ICC) 0.14 for PT and 0.56 for OT. After accounting for the hospital where they were admitted, African-Americans were more likely to receive PT (OR 1.11) and OT (OR 1.08, p < 0.05) and therapy use was the same in Hispanics and whites (OR 1.05 for PT, p = 0.3 and 1.10 for OT, p = 0.09).

Conclusions: In this large sample, African-Americans and Hispanics were less likely to receive inpatient PT and OT than whites. This disparity is explained by the fact that minorities receive care at hospitals that use less PT and OT. Optimizing therapy use in these hospitals may improve stroke outcomes and reduce outcome disparities.

Abstract W MP108: Identifying Factors Predictive of Good Outcome among Patients with Severe Ischemic Stroke: the BASIC Project

Background: Utilizing a population-based stroke surveillance study, our objective was to identify possible socio-demographic, cultural and psychological factors that influence outcome among patients with severe stroke who survive at least 3 months.

Methods: Ischemic strokes (IS) were identified utilizing the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Severe stroke was defined as the highest quartile of the initial NIH Stroke Scale (NIHSS ≥ 8). Functional outcome was assessed at 90 days using the ADL/IADL score (0-4, higher worse). Good outcome was defined as ADL/IADL <3. Single predictor logistic regression models were used to identify predictors of good outcome among those with severe stroke. Backward elimination was then used to select a final set of predictors. Next, models including selected predictors and pre-stroke social support or pre-stroke depression (PHQ-9) were used to evaluate their association with good outcome among a subset of patients who were asked about these factors. Only patients who were able to answer their own questions were asked about depression and social support.

Results: From Feb 2009 to Jun 2012, 646 IS patients completed a baseline interview and subsequent 90-day outcome interview. Of 168 with severe stroke, 68 had a good outcome at 3 months (ADL/IADL <3). One year older age (OR=0.94, 95% confidence interval (CI) 0.91, 0.97), Mexican American ethnicity (OR 0.30, 95%CI: 0.13, 0.68), stroke history (OR 0.27, 95%CI: 0.11, 0.66) and higher pre-stroke modified Rankin of 4-5 (OR 0.28, 95%CI: 0.08, 0.93) were associated with lower odds of good outcome. Among the subset of severe stroke patients (N=93) asked about pre-stroke depression and social support, higher pre-stroke depression score was associated with lower odds of good outcome (OR: 0.89, 95%CI 0.79, 0.99) while greater pre-stroke social support was associated with higher odds of good outcome (OR: 1.45, 95% CI 1.13, 1.86).

Conclusion: Among IS survivors with severe stroke, pre-stroke depression and social support are important predictors of good outcome. These factors should be considered in crafting interventions to improve stroke outcome. Mexican American ethnicity and history of prior stroke are strongly negatively associated with good stroke outcome.

Factors influencing sex differences in poststroke functional outcome

BACKGROUND AND PURPOSE

Our objective was to identify factors that contribute to or modify the sex difference in poststroke functional outcome.

METHODS

Ischemic strokes (n=439) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2008-2011). Data were ascertained from interviews (baseline and 90 days post stroke) and medical records. Functional outcome was measured as an average of 22 activities of daily living (ADL)/instrumental ADL items (range, 1-4; higher scores worse function). Tobit regression was used to estimate sex differences and to identify confounding and modifying factors.

RESULTS

Fifty-one percent were women. Median age was 71 (interquartile range, 59-80) years in women and 64 (interquartile range, 56-77) years in men. Median ADL/instrumental ADL score at 90 days was 2.7 (interquartile range, 1.8-3.6) in women and 2.0 (interquartile range, 1.3-3.1) in men (P<0.01); this difference remained after age-adjustment (P<0.001). Factors contributing to higher ADL/instrumental ADL scores in women included prestroke function, marital status, prestroke cognition, nursing home residence, stroke severity, history of stroke/transient ischemic attack, and body mass index; prestroke function was the largest contributor. Stroke severity modified the sex difference in outcome such that differences were apparent for mild to moderate but not severe strokes. After adjustment, women still had significantly worse functional outcome than men.

CONCLUSIONS

These findings yield insight into possible strategies and subgroups to target to reduce the sex disparity in stroke outcome; demographics and prestroke and clinical factors explained only 41% of the sex difference in stroke outcome highlighting the need for future research to identify modifiable factors that contribute to sex differences.

The role of accommodations in poststroke disability management

OBJECTIVE

To explore use of assistive devices and personal assistance and unmet need for assistance among older stroke survivors and identify potentially modifiable factors to optimize self-care and mobility activities in this population.

METHOD

Using the 2011 National Health and Aging Trends Study, we compared demographic characteristics, accommodation-enabling factors and need-related factors for self-reported stroke survivors (N = 892) and stroke-free controls (N = 6,709). For individual self-care and mobility activities, we examined type of accommodation (no devices/no help, devices/no help, devices/help, help/no devices) and unmet need by stroke status. For the sample of stroke survivors, we then estimated (a) multinomial logistic regression models predicting type of accommodation and (b) logistic regression models predicting unmet need.

RESULTS

Stroke survivors used more assistive devices and received more personal assistance and had greater unmet need than stroke-free controls. In adjusted models, physical and cognitive capacity measures were most important in predicting accommodations and accommodations most important in predicting unmet need.

DISCUSSION

Although accommodations are commonly used by older adult stroke survivors, unmet need is also substantial. Future research should focus on finding ways to improve poststroke functional capacity and cognitive capacity and enhance adoption of assistive devices with the aim of reducing unmet need.

Racial and Ethnic Differences in Mental Distress among Stroke Survivors

OBJECTIVE

African Americans, Hispanics and some Asian subgroups have a higher stroke incidence than non-Hispanic Whites (NHW). Additionally, African Americans and Hispanics have worse stroke outcomes than non-Hispanic Whites. Thus, we explored racial and ethnic differences in mental distress, a known risk factor for post-stroke disability.

METHODS

National Health Interview Survey data from 2000-2010 were used to identify 8,324 community dwelling adults with self-reported stroke. Serious mental distress was identified by the Kessler-6 scale. Logistic regression models assessed racial/ethnic associations with serious mental distress after adjusting for demographics, comorbidities, disability, health care utilization and socioeconomic factors.

RESULTS

Serious mental distress was identified in 9% of stroke survivors. Hispanics (14%) were more likely to have serious mental distress than African Americans (9%), non-Hispanic Whites (9%) and Asians (8%, P = .02). After adjustment, Hispanics (OR = 1.06, 95% CI .76-1.48) and Asians (.84, 95% Cl .37-1.90) had a similar odds of serious mental distress while African Americans had a lower odds of serious mental distress (OR = .61, 95% CI .48-.78) compared with non-Hispanic Whites. Younger age, low levels of education and insurance were important predictors of serious mental distress among Hispanics.

CONCLUSION

Serious mental distress is highly prevalent among US stroke survivors and is more common in Hispanics than NHWs, African Americans and Asians. Further study of the role of mental distress in ethnic differences in post-stroke disability is warranted.

Creating a Novel Video Vignette Stroke Preparedness Outcome Measure Using a Community-Based Participatory Approach

Evaluating the efficacy of behavioral interventions for rare outcomes is a challenge. One such topic is stroke preparedness, defined as inteventions to increase stroke symptom recognition and behavioral intent to call 911. Current stroke preparedness intermediate outcome measures are centered on written vignettes or open-ended questions and have been shown to poorly reflect actual behavior. Given that stroke identification and action requires aural and visual processing, video vignettes may improve on current measures. This article discusses an approach for creating a novel stroke preparedness video vignette intermediate outcome measure within a community-based participatory research partnership. A total of 20 video vignettes were filmed of which 13 were unambiguous (stroke or not stroke) as determined by stroke experts and had test discrimination among community participants. Acceptable reliability, high satisfaction, and cultural relevance were found among the 14 community respondents. A community-based participatory approach was effective in creating a video vignette intermediate outcome. Future projects should consider obtaining expert and community feedback prior to filming all the video vignettes to improve the proportion of vignettes that are usable. While content validity and preliminary reliability were established, future studies are needed to confirm the reliability and establish construct validity.

Loss of the Mexican American survival advantage after ischemic stroke

BACKGROUND AND PURPOSE

Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design.

METHODS

Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences.

RESULTS

There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P=0.24) and 1 year (20.8% to 15.5%; P=0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% (P=0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality (P=0.26). Although ethnic differences in 30-day (P=0.01) and 1-year (P=0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P=0.63; 1-year mortality, P=0.92).

CONCLUSIONS

Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.

Impact of state Medicaid coverage on utilization of inpatient rehabilitation facilities among patients with stroke

BACKGROUND AND PURPOSE

Poststroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among patients with stroke.

METHODS

Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample. Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tissue-type plasminogen activator use, state Medicaid IRF coverage, and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering.

RESULTS

Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (P for interaction <0.01). Compared with Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF of 11.6% (95% confidence interval, 8.5%-14.7%) versus 19.5% (95% confidence interval, 18.3%-20.8%), P<0.01 after full adjustment.

CONCLUSIONS

State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for poststroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted.

Racial differences in disability after stroke: results from a nationwide study

OBJECTIVE

We sought to characterize racial differences in disability among older stroke survivors.

METHODS

A cross-sectional study of 806 self-reported stroke survivors from the 2011 National Health and Aging Trends Study was performed. Race was based on self-report. Primary outcome was activity limitations (requiring assistance with mobility, self-care, and household activities). Secondary outcome was participation restrictions, which were defined as reductions/absence in valued social activities because of health. Physical capacity was measured by a validated scale (0 low-12 high). Logistic regression was used to estimate average marginal effects of activity limitations and participation restrictions by race before and after adjusting for sociodemographics, comorbidities, and physical and cognitive capacity.

RESULTS

Non-Hispanic black participants had lower physical capacity than non-Hispanic white participants (mean 5.1 vs 6.9, p < 0.01). For most activities, black participants had significantly greater limitations than white participants. These differences persisted after accounting for sociodemographic factors and comorbidities, but largely became nonsignificant after accounting for physical capacity. The only unadjusted racial difference in participation restriction was in religious service attendance (18.2% of white participants vs 28.6% of black participants, p < 0.01).

CONCLUSION

After stroke, black individuals have a greater prevalence of activity limitations than white individuals, largely due to their greater physical capacity limitations. Further understanding of the causes of racial differences in capacity after stroke is needed to reduce activity limitations after stroke and decrease racial disparities.

Influence of hospital-level practices on readmission after ischemic stroke

OBJECTIVE

To inform stroke quality improvement initiatives by determining the relationship between hospital-level stroke practices and readmission after accounting for patient-level factors.

METHODS

Retrospective cohort study of adult patients hospitalized for ischemic stroke (principal ICD-9-CM codes 433.x1, 434.x1, and 436) in 5 states from 2003 to 2009 from State Inpatient Databases. The primary outcome was any unplanned readmission within 30 days. Multilevel logistic regression was used to estimate the association between hospital-level practice patterns of care (diagnostic testing, procedures, intensive care unit, tissue plasminogen activator, and therapeutic modalities) and readmission after adjustment for patient factors and whether individual patients received a given practice.

RESULTS

Thirty-day unplanned readmission occurred in 15.2% of stroke admissions; the median hospital readmission rate was 13.6% (interquartile range 9.8%-18.2%). Of the 25 hospital practice patterns of care analyzed, 3 practices were associated with readmission: hospitals with higher use of occupational therapy and higher proportion of transfers from other hospitals had lower adjusted readmission rates, whereas hospitals with higher use of hospice had higher predicted readmission rates. Readmission rates in lowest vs highest utilizing quintile were as follows: occupational therapy 16.2% (95% confidence interval [CI] 14.5%-18.0%) vs 12.3% (95% CI 11.3%-13.2%); transfers 13.8% (95% CI 13.2%-14.5%) vs 12.5% (95% CI 11.6%-13.5%); and hospice 13.1% (95% CI 12.3%-14.0%) vs 14.8% (95% CI 13.5%-16.1%).

CONCLUSIONS

Hospital practices have a role in stroke readmission that is complex and poorly understood. Further work is needed to identify specific strategies to reduce readmission rates and to ensure that public reporting of readmission rates will not result in adverse unintended consequences.

Minorities, men, and unmarried amyotrophic lateral sclerosis patients are more likely to die in an acute care facility

Studies suggest that dying at home is a more favorable experience. This study investigated where amyotrophic lateral sclerosis (ALS) patients die and the patient demographics associated with dying in an acute care facility or nursing home compared to home or hospice. Centers for Disease Control and Prevention Multiple Cause Mortality Files from 2005 to 2010 were used to identify ALS patients and to classify place of death. Multinomial logistic regression was used to determine the association between patient demographics and place of death. Between 2005 and 2010, 40,911 patients died of ALS in the United States. Place of death was as follows: home or hospice facility 20,231 (50%), acute care facility (25%), and nursing home (20%). African Americans (adjusted multinomial odds ratio (aMOR) 2.56, CI 2.32-2.83), Hispanics (aMOR 1.44, CI 1.30-1.62), and Asians (aMOR 1.87, CI 1.57-2.22) were more likely to die in an acute care facility, whereas females (aMOR 0.76, CI 0.72-0.80) and married individuals were less likely. Hispanics (aMOR 0.68, CI 0.58-0.79) and married individuals were less likely to die in a nursing home. In conclusion, minorities, men, and unmarried individuals are more likely to die in an acute care facility. Further studies are needed to better understand place of death preferences.

Intracerebral hemorrhage mortality is not changing despite declining incidence

OBJECTIVE

To determine trends in incidence and mortality of intracerebral hemorrhage (ICH) in a rigorous population-based study.

METHODS

We identified all cases of spontaneous ICH in a South Texas community from 2000 to 2010 using rigorous case ascertainment methods within the Brain Attack Surveillance in Corpus Christi Project. Yearly population counts were determined from the US Census, and deaths were determined from state and national databases. Age-, sex-, and ethnicity-adjusted incidence was estimated for each year with Poisson regression, and a linear trend over time was investigated. Trends in 30-day case fatality and long-term mortality (censored at 3 years) were estimated with log-binomial or Cox proportional hazards models adjusted for demographics, stroke severity, and comorbid disease.

RESULTS

A total of 734 cases of ICH were included. The age-, sex-, and ethnicity-adjusted ICH annual incidence rate was 5.21 per 10,000 (95% confidence interval [CI] 4.36, 6.24) in 2000 and 4.30 per 10,000 (95% CI 3.21, 5.76) in 2010. The estimated 10-year change in demographic-adjusted ICH annual incidence rate was -31% (95% CI -47%, -11%). Yearly demographic-adjusted 30-day case fatality ranged from 28.3% (95% CI 19.9%, 40.3%) in 2006 to 46.5% (95% CI 35.5, 60.8) in 2008. There was no change in ICH case fatality or long-term mortality over time.

CONCLUSIONS

ICH incidence decreased over the past decade, but case fatality and long-term mortality were unchanged. This suggests that primary prevention efforts may be improving over time, but more work is needed to improve ICH treatment and reduce the risk of death.

Consumer Demand for Online Dizziness Information: If You Build it, They may Come

OBJECTIVE

Dizziness is a common reason patients present to doctors, but effective diagnostic tests and treatments for dizziness are underused. The internet is a way to disseminate medical information and is emerging as an intervention platform. The objective of this study was to describe internet searches for dizziness terms to assess the possible consumer demand for internet-based dizziness diagnostic and treatment tools.

STUDY DESIGN/METHODS

Google AdWords and Google Insights for Search were used for keyword search data on the following generic terms: vertigo, dizzy, dizziness, lightheaded, and lightheadedness. Data collected included keyword ideas (i.e., additional keywords identified by Google as being related search terms), global and US only monthly search frequencies, as well as trends in top searches related to dizziness terms from 2004 to 2012. Keywords suggestive of benign paroxysmal positional vertigo (BPPV) or BPPV processes were identified.

RESULTS

Of the five generic dizziness terms, vertigo had the most global searches per month (1.83 million) and lightheadedness had the least (90,500). Four BPPV-specific terms had more than 100,000 global searches per month. Three BPPV terms ("positional vertigo," "benign vertigo," and "benign positional vertigo") have been in the list of top searches related to vertigo every quarter since 2004.

CONCLUSION

Substantial demand exists for dizziness information via the internet. Future studies should seek to better characterize the population seeking this information. The magnitude of this potential demand suggests that validated and tested diagnostic and treatment tools could contribute to healthcare efficiencies and patient outcomes.

Neurological, functional, and cognitive stroke outcomes in Mexican Americans

BACKGROUND AND PURPOSE

Our objective was to compare neurological, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites using data from a population-based study.

METHODS

Ischemic strokes (2008-2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days poststroke) and medical records. Ethnic differences in neurological (National Institutes of Health Stroke Scale: range, 0-44; higher scores worse), functional (activities of daily living/instrumental activities of daily living score: range, 1-4; higher scores worse), and cognitive (Modified Mini-Mental State Examination: range, 0-100; lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors.

RESULTS

A total of 513, 510, and 415 subjects had complete data for neurological, functional, and cognitive outcomes and covariates, respectively. Median age was 66 (interquartile range, 57-78); 64% were MAs. In MAs, median National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living, and Modified Mini-Mental State Examination score were 3 (interquartile range, 1-6), 2.5 (interquartile range, 1.6-3.5), and 88 (interquartile range, 76-94), respectively. MAs scored 48% worse (95% CI, 23%-78%) on National Institutes of Health Stroke Scale, 0.36 points worse (95% CI, 0.16-0.57) on activities of daily living/instrumental activities of daily living score, and 3.39 points worse (95% CI, 0.35-6.43) on Modified Mini-Mental State Examination than non-Hispanic whites after multivariable adjustment.

CONCLUSIONS

MAs scored worse than non-Hispanic whites on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial.

Abstract W P48: Marked Regional Variation in Acute Stroke Treatment in Medicare Beneficiaries

Objective: Regionalization of stroke care has occurred sporadically across the U.S, so determining realistic goal treatment rates for individual regions or the nation as a whole is challenging. Studies of a single hospital or region vary widely in estimates of eligibility for acute therapy and may have limited generalizability or biases. We hypothesized that the proportion of U.S. Medicare beneficiaries receiving acute stroke therapy varies by region. Treatment rates in high performing regions may represent realistic national goals and inform policy to increase treatment rates.

Methods: All Medicare beneficiaries with a principal diagnosis of ischemic stroke (ICD-9 433.x1, 434.x1, 436) admitted through the emergency department were identified using MEDPAR files from 2007-2010. Receipt of IV tPA (DRG 559, MS-DRG 61-63, ICD-9 procedure code 99.10) or IA thrombolysis (CPT code 37184-6, 37201, 75896 via linked Medicare Carrier files) was determined. Patients were assigned to one of 3,436 Hospital Service Areas (HSA; local health care markets for hospital care) by zip code. Regional acute stroke treatment rates were calculated and the lowest and highest quintiles were compared. Multi-level logistic regression was used to adjust for individual demographics as well as regional population density, education, median income, and unemployment using linked census data. Model-based adjusted regional acute stroke treatment rates were estimated.

Results: Of 916,232 stroke admissions 3.6% received IV tPA only and 0.6% received IA or combined therapy. Unadjusted treatment rates by region ranged from 0.8% (minimum) to 14.8% (maximum). Regional rates ranged from 1.7% (quintile 1) to 5.4% (quintile 5). Regions with higher education, population density and income had higher treatment rates (p <= 0.001). After adjustment, regional differences were attenuated slightly _ 1.9% (quintile 1) to 5.1% (quintile 5).

Conclusions: Marked variation exists in acute stroke treatment rates by region, even after adjusting for patient and regional characteristics, supporting the perception that a major opportunity exists to improve acute stroke treatment within many HSAs.

Smoking and mortality in stroke survivors: can we eliminate the paradox?

BACKGROUND

Many studies have suggested that smoking does not increase mortality in stroke survivors. Index event bias, a sample selection bias, potentially explains this paradoxical finding. Therefore, we compared all-cause, cardiovascular disease (CVD), and cancer mortality by cigarette smoking status among stroke survivors using methods to account for index event bias.

METHODS

Among 5797 stroke survivors of 45 years or older who responded to the National Health Interview Survey years 1997-2004, an annual, population-based survey of community-dwelling US adults, linked to the National Death Index, we estimated all-cause, CVD, and cancer mortality by smoking status using Cox proportional regression and propensity score analysis to account for demographic, socioeconomic, and clinical factors. Mean follow-up was 4.5 years.

RESULTS

From 1997 to 2004, 18.7% of stroke survivors smoked. There were 1988 deaths in this stroke survivor cohort, with 50% of deaths because of CVD and 15% because of cancer. Current smokers had an increased risk of all-cause mortality (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.14-1.63) and cancer mortality (HR, 3.83; 95% CI, 2.48-5.91) compared with never smokers, after controlling for demographic, socioeconomic, and clinical factors. Current smokers had an increased risk of CVD mortality controlling for age and sex (HR, 1.29; 95% CI, 1.01-1.64), but this risk did not persist after controlling for socioeconomic and clinical factors (HR, 1.15; 95% CI, .88-1.50).

CONCLUSIONS

Stroke survivors who smoke have an increased risk of all-cause mortality, which is largely because of cancer mortality. Socioeconomic and clinical factors explain stroke survivors' higher risk of CVD mortality associated with smoking.

Association of body mass index and mortality after acute ischemic stroke

BACKGROUND

The prevalence of severe obesity is rising in the United States. Although mild to moderately elevated body mass index (BMI) is associated with reduced mortality after acute ischemic stroke, less is known about severe obesity.

METHODS AND RESULTS

Patients with acute ischemic stroke (n=1791) ≥45 years were identified from the biethnic population-based Brain Attack Surveillance in Corpus Christi (BASIC) study from June 1, 2005, to December 31, 2010. Median follow-up was 660 days. BMI was abstracted from the medical record. Survival was estimated by BMI category (underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and severe obesity) using Kaplan-Meier methods. Hazard ratios for the relationship between BMI modeled continuously and mortality were estimated from Cox regression models after adjustment for patient factors. The median BMI was 27.1 kg/m(2) (interquartile range, 23.7-31.2 kg/m(2)), and 56% were Mexican American. A total of 625 patients (35%) died during the study period. Persons with higher baseline BMI had longer survival in unadjusted analysis (P<0.01). After adjustment for demographics, stroke severity, and stroke and mortality risk factors, the relationship between BMI and mortality was U shaped. The lowest mortality risk was observed among patients with an approximate BMI of 35 kg/m(2), whereas those with lower or higher BMI had higher mortality risk.

CONCLUSIONS

Severe obesity is associated with increased poststroke mortality in middle-aged and older adults. Stroke patients with class 2 obesity had the lowest mortality risk. More research is needed to determine weight management goals among stroke survivors.

Understanding stroke survivorship: expanding the concept of poststroke disability

BACKGROUND AND PURPOSE

Limitations in essential daily activities are common among older adults after stroke, but little is known about restrictions in their ability to participate in valued social activities. We sought to broaden our understanding of disability after stroke by characterizing poststroke participation restrictions and investigating the extent to which they are accounted for by differences in physical and cognitive capacity, aphasia/dysarthria, depressive, and anxiety symptoms.

METHODS

Data from the 2011 National Health and Aging Trends Study (NHATS) were used to identify 892 self-reported stroke survivors aged≥65 years. One-to-one propensity matching was performed on demographics and comorbidities to create a matched sample. Participation restrictions were defined as reductions/absence in social activities valued by respondents because of their health or functioning. Physical and cognitive capacity, depressive and anxiety symptoms were measured by validated scales and aphasia/dysarthria by a single question. Comparisons using survey-weighted χ2 tests and logistic regression were made.

RESULTS

Stroke survivors had more participation restrictions (32.8% versus 23.5%; odds ratio, 1.59; 95% confidence interval, 1.28-1.95; P<0.01) than controls. Differences between stroke survivors and controls in any participation restriction and several components (attending religious service, clubs/classes, and going out for enjoyment) were eliminated after adjusting for physical capacity. Depressive and anxiety symptoms and aphasia/dysarthria were independent predictors of participation restrictions.

CONCLUSIONS

Stroke survivors have more participation restrictions than can be accounted for by sociodemographic profiles and comorbidity burden. Future work aimed at improving physical capacity, reducing depressive and anxiety symptoms, and improving aphasia/dysarthria has potential to enhance participation.

The accuracy of surrogate decision makers: informed consent in hypothetical acute stroke scenarios

Background

Over one third of stroke patients have cognitive or language deficits such that they require surrogate consent for acute stroke treatment or enrollment into acute stroke trials. Little is known about the agreement of stroke patients and surrogates in this time-sensitive decision-making process. We sought to determine patient and surrogate agreement in 4 hypothetical acute stroke scenarios.

Methods

We performed face to face interviews with ED patients at an academic teaching hospital from June to August 2011. Patients and the surrogates they designated were asked to make decisions regarding 4 hypothetical stroke scenarios: 2 were treatment decisions; 2 involved enrollment into a clinical trial. Percent agreement was calculated as measures of surrogate predictive ability.

Results

A total of 200 patient/surrogate pairs were interviewed. Overall patient/surrogate percent agreement was 76.5%. Agreement for clinical scenarios ranged from 87% to 96% but dropped to 49%-74% for research scenarios.

Conclusions

Surrogates accurately predict patient preferences for standard acute stroke treatments. However, the accuracy decreases when predicting research participation suggesting that the degree of surrogate agreement is dependent on the type of decision being made. Further research is needed to more thoroughly characterize surrogate decision-making in acute stroke situations.

Stroke awareness among inpatient nursing staff at an academic medical center

BACKGROUND AND PURPOSE

Because 10% of strokes occur in hospitalized patients, we sought to evaluate stroke knowledge and predictors of stroke knowledge among inpatient and emergency department nursing staff.

METHODS

Nursing staff completed an online stroke survey. The survey queried outcome expectations (the importance of rapid stroke identification), self-efficacy in recognizing stroke, and stroke knowledge (to name 3 stroke warning signs or symptoms). Adequate stroke knowledge was defined as the ability to name ≥2 stroke warning signs. Logistic regression was used to identify the association between stroke symptom knowledge and staff characteristics (education, clinical experience, and nursing unit), stroke self-efficacy, and outcome expectations.

RESULTS

A total of 875 respondents (84% response rate) completed the survey and most of the respondents were nurses. More than 85% of respondents correctly reported ≥2 stroke warning signs or symptoms. Greater self-efficacy in identifying stroke symptoms (odds ratio, 1.13; 95% confidence interval, 1.01-1.27) and higher ratings for the importance of rapid identification of stroke symptoms (odds ratio, 1.23; 95% confidence interval, 1.002-1.51) were associated with stroke knowledge. Clinical experience, educational experience, nursing unit, and personal knowledge of a stroke patient were not associated with stroke knowledge.

CONCLUSIONS

Stroke outcome expectations and self-efficacy are associated with stroke knowledge and should be included in nursing education about stroke.

Does socioeconomic status or acculturation modify the association between ethnicity and hypertension treatment before stroke?

BACKGROUND AND PURPOSE

Socioeconomic status and acculturation may modify the association between ethnicity and hypertension treatment before stroke. We assessed prestroke treatment of hypertension by ethnicity, education (proxy for socioeconomic status), and English proficiency (EP; proxy for acculturation) in a population-based stroke surveillance project.

METHODS

Among 763 patients with first-ever stroke aged ≥45 years in the Brain Attack Surveillance in Corpus Christi project from 2000 to 2006, we examined self-reported hypertension treatment at the time of the stroke by ethnicity (Mexican American [MA] versus non-Hispanic white [NHW]) in the overall sample, within education strata (<high school, high school, >high school), and after dichotomizing MAs by self-reported EP (limited versus proficient). Logistic regression adjusted associations for age, sex, education, diabetes mellitus, coronary artery disease, hypercholesterolemia, and health insurance.

RESULTS

NHWs and MAs reported similar hypertension treatment (84% versus 86%; P=0.53). Hypertension treatment was 84% for NHWs and 90% for MAs (P=0.18) in <high school stratum, 87% for NHWs and 75% for MAs (P=0.07) in high school stratum, and 81% for NHWs and 78% for MAs (P=0.73) in >high school stratum (ethnicity-by-education interaction, P=0.09). Hypertension treatment was 83% for NHWs, 87% for MAs with EP (PvsNHWs=0.35), and 90% for MAs with limited EP (PvsNHWs=0.13; ethnicity-by-EP interaction, P=0.22). Hypertension treatment was lower in uninsured patients (adjusted odds ratio, 0.13; 95% confidence interval, 0.03-0.60) or those with no physician visit ≤6 months (adjusted odds ratio, 0.09; 95% confidence interval, 0.03-0.24).

CONCLUSIONS

We found no evidence that socioeconomic status or acculturation modifies the association between ethnicity and hypertension treatment before stroke.

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans

OBJECTIVE

To determine trends in ischemic stroke incidence among Mexican Americans and non-Hispanic whites.

METHODS

We performed population-based stroke surveillance from January 1, 2000 to December 31, 2010 in Corpus Christi, Texas. Ischemic stroke patients 45 years and older were ascertained from potential sources, and charts were abstracted. Neurologists validated cases based on source documentation blinded to ethnicity and age. Crude and age-, sex-, and ethnicity-adjusted annual incidence was calculated for first ever completed ischemic stroke. Poisson regression models were used to calculate adjusted ischemic stroke rates, rate ratios, and trends.

RESULTS

There were 2,604 ischemic strokes in Mexican Americans and 2,042 in non-Hispanic whites. The rate ratios (Mexican American:non-Hispanic white) were 1.94 (95% confidence interval [CI] = 1.67-2.25), 1.50 (95% CI = 1.35-1.67), and 1.00 (95% CI = 0.90-1.11) among those aged 45 to 59, 60 to 74, and 75 years and older, respectively, and 1.34 (95% CI = 1.23-1.46) when adjusted for age. Ischemic stroke incidence declined during the study period by 35.9% (95% CI = 25.9-44.5). The decline was limited to those aged ≥60 years, and happened in both ethnic groups similarly (p > 0.10), implying that the disparities seen in the 45- to 74-year age group persist unabated.

INTERPRETATION

Ischemic stroke incidence rates have declined dramatically in the past decade in both ethnic groups for those aged ≥60 years. However, the disparity between Mexican American and non-Hispanic white stroke rates persists in those <75 years of age. Although the decline in stroke is encouraging, additional prevention efforts targeting young Mexican Americans are warranted.

Traumatic brain injury may be an independent risk factor for stroke

OBJECTIVE

To explore whether traumatic brain injury (TBI) may be a risk factor for subsequent ischemic stroke.

METHODS

Patients with any emergency department visit or hospitalization for TBI (exposed group) or non-TBI trauma (control) based on statewide emergency department and inpatient databases in California from 2005 to 2009 were included in a retrospective cohort. TBI was defined using the Centers for Disease Control definition. Our primary outcome was subsequent hospitalization for acute ischemic stroke. The association between TBI and stroke was estimated using Cox proportional hazards modeling adjusting for demographics, vascular risk factors, comorbidities, trauma severity, and trauma mechanism.

RESULTS

The cohort included a total of 1,173,353 trauma subjects, 436,630 (37%) with TBI. The patients with TBI were slightly younger than the controls (mean age 49.2 vs 50.3 years), less likely to be female (46.8% vs 49.3%), and had a higher mean injury severity score (4.6 vs 4.1). Subsequent stroke was identified in 1.1% of the TBI group and 0.9% of the control group over a median follow-up period of 28 months (interquartile range 14-44). After adjustment, TBI was independently associated with subsequent ischemic stroke (hazard ratio 1.31, 95% confidence interval 1.25-1.36).

CONCLUSIONS

In this large cohort, TBI is associated with ischemic stroke, independent of other major predictors.

Individual and community determinants of calling 911 for stroke among African Americans in an urban community

BACKGROUND

African Americans receive acute stroke treatment less often than non-Hispanic whites. Interventions to increase stroke preparedness (recognizing stroke warning signs and calling 911) may decrease the devastating effects of stroke by allowing more patients to be candidates for acute stroke therapy. In preparation for such an intervention, we used a community-based participatory research approach to conduct a qualitative study exploring perceptions of emergency medical care and stroke among urban African American youth and adults.

METHODS AND RESULTS

Community partners, church health teams, and church leaders identified and recruited focus group participants from 3 black churches in Flint, MI. We conducted 5 youth (11-16 years) and 4 adult focus groups from November 2011 to March 2012. A content analysis approach was taken for analysis. Thirty-nine youth and 38 adults participated. Women comprised 64% of youth and 90% of adult focus group participants. All participants were black. Three themes emerged from the adult and youth data: (1) recognition that stroke is a medical emergency; (2) perceptions of difficulties within the medical system in an under-resourced community, and; (3) need for greater stroke education in the community.

CONCLUSIONS

Black adults and youth have a strong interest in stroke preparedness. Designs of behavioral interventions to increase stroke preparedness should be sensitive to both individual and community factors contributing to the likelihood of seeking emergency care for stroke.

Choosing Wisely: highest-cost tests in outpatient neurology

Identifying the tests/procedures ordered by neurologists that contribute most to health care expenditures is a critical step in the process of creating the neurology top 5 list for the Choosing Wisely initiative. Using data from the 2007-2010 National Ambulatory Care Medical Survey, we found that $13.3 billion (95% confidence interval = $10.1-$16.5 billion) was spent on tests ordered at neurologist visits. The tests/procedures with the highest expenditures were magnetic resonance imaging (MRI; 51% of total expenditures; $7.5 billion), electromyography (EMG; 20% of expenditures; $2.6 billion), and electroencephalography (EEG; 8% of expenditures; $1.1 billion). MRI, EMG, and EEG should receive close scrutiny in the development of the neurology top 5 list.

Abstract WP405: Sex Differences in Post-Stroke Functional Outcomes

Background: Studies consistently show that women have less favorable functional outcomes after stroke than men but the causes are uncertain. Our objective was to assess sex differences in functional outcomes measured 90-days post event in a population-based stroke study and to identify which pre-stroke factors and clinical stroke characteristics explain sex differences.

Methods: Ischemic stroke patients (n=398) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2008-2011). Data were ascertained from in-person patient or proxy interviews (baseline and 90 days post-stroke) and medical records. Functional outcome at 90 days was measured as total ADL/IADL score (range 22-88, higher scores indicate poorer function). Tobit regression was used to estimate sex differences in outcome. To identify clinically important confounding factors, individual variables were added to age-adjusted models to determine if the sex difference changed by ≥ 5%. A final multivariable model was run including sex, age, ethnicity, and identified confounders.

Results: Median age was 69 (IQR: 57, 79) and 52% were women. In crude and age-adjusted models women scored 11.2 points (p<0.001) and 8.7 points (p<0.001) higher on the ADL/IADL score respectively. After accounting for age, stroke severity, pre-stroke functional and cognitive status, pre-stroke comorbidity index, nursing home residence, history of stroke/TIA, BMI and marital status were all clinically important confounders of the sex difference. In the final multivariable model, a sex difference in functional outcome remained, with women scoring 6.2 points higher on the ADL/IADL score than men (p<0.01).

Conclusions: Women had poorer functional outcomes post stroke even after accounting for differences in age, pre-stroke confounding factors and stroke severity. Age, pre-stroke factors and stroke severity explained about half of the total observed sex difference. Further research is needed to identify the reasons why women have poorer outcomes in order to design interventions aimed at reducing stroke disability in women.

Does preexisting antiplatelet treatment influence postthrombolysis intracranial hemorrhage in community-treated ischemic stroke patients? An observational study

OBJECTIVES

Intracranial hemorrhage (ICH) after acute stroke thrombolysis is associated with poor outcomes. Previous investigations of the relationship between preexisting antiplatelet use and the safety of intravenous (IV) thrombolysis have been limited by low event rates. The objective of this study was to determine whether preexisting antiplatelet therapy increased the risk of ICH following acute stroke thrombolysis. The primary hypothesis was that antiplatelet use would not be associated with radiographic evidence of ICH after controlling for relevant confounders.

METHODS

Consecutive cases of thrombolysis patients treated in the emergency department (ED) were identified using multiple methods. Retrospective data were collected from four hospitals from 1996 to 2004 and 24 other hospitals from 2007 to 2010 as part of a cluster-randomized trial. The same chart abstraction tool was used during both time periods, and data were subjected to numerous quality control checks. Hemorrhages were classified using a prespecified methodology: ICH was defined as presence of hemorrhage in radiographic interpretations of follow-up imaging (primary outcome). Symptomatic ICH (sICH) was defined as radiographic ICH with associated clinical worsening. A multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to postthrombolysis ICH. Sensitivity analyses were conducted where the unadjusted and adjusted results from this study were combined with those of previously published external studies on this topic via meta-analytic techniques.

RESULTS

There were 830 patients included, with 47% having documented preexisting antiplatelet treatment. The mean (± standard deviation [SD]) age was 69 (± 15) years, and the cohort was 53% male. The unadjusted proportion of patients with any ICH was 15.1% without antiplatelet use and 19.3% with antiplatelet use (absolute risk difference = 4.2%, 95% confidence interval [CI] = -1.2% to 9.6%); for sICH this was 6.1% without antiplatelet use and 9% with antiplatelet use (absolute risk difference = 3.1%, 95% CI = -1% to 6.7%). After adjusting for confounders, antiplatelet use was not significantly associated with radiographic ICH (odds ratio [OR] = 1.1, 95% CI = 0.8 to 1.7) or sICH (OR = 1.3, 95% CI = 0.7 to 2.2). In patients 81 years and older, there was a higher risk of radiographic ICH (absolute risk difference = 11.9%, 95% CI = 0.1% to 23.6%). The meta-analyses combined the findings of this investigation with previous similar work and found increased unadjusted risks of radiographic ICH (absolute risk difference = 4.9%, 95% CI = 0.7% to 9%) and sICH (absolute risk difference = 4%, 95% CI = 2.3% to 5.6%). The meta-analytic adjusted OR of sICH for antiplatelet use was 1.6 (95% CI = 1.1 to 2.4).

CONCLUSIONS

The authors did not find that preexisting antiplatelet use was associated with postthrombolysis ICH or sICH in this cohort of community treated patients. Preexisting tobacco use, younger age, and lower severity were associated with lower odds of sICH. The meta-analyses demonstrated small, but statistically significant increases in the absolute risk of radiographic ICH and sICH, along with increased odds of sICH in patients with preexisting antiplatelet use.