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McCarthy MJ, Wells A, Schellinger J, Bird A. At the Intersection of Race, Socioeconomics, and Chronic Illness: A Case and Frame Analysis of Two Survivor-Caregiver Dyads in the Aftermath of Stroke. SOCIAL WORK IN PUBLIC HEALTH 2022; 37:57-70. [PMID: 34486499 DOI: 10.1080/19371918.2021.1974637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although the overall incidence of stroke in the United States has decreased in recent years, the incidence of stroke among Black Americans has not changed. This has resulted in a widening gap between White and Black stroke survivors and their families. A variety of factors contribute to this inequity including social determinants of health (e.g., adverse life events, discrimination, neighborhood deprivation, lack of access to health care). This article uses a "case and frame" approach, through the lens of ecological systems theory, to illustrate how social determinants of health express themselves in two stroke survivor-caregiver dyads living in a large Midwestern city. We draw out implications for practice and policy in social work and related disciplines that focus on recognizing the impact of social determinants of health, developing culturally-specific interventions that mitigate unique stressors but that also leverage unique strengths, and building capacity for cultural competence and cross-cultural health communication within organizations.
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Affiliation(s)
- Michael J McCarthy
- Department of Social Work, College of Social and Behavioral Sciences, Northern Arizona University, Flagstaff, Arizona, USA
| | - Anjanette Wells
- School of Social Work, College of Allied Health Sciences, University of Cincinnati, Cinainnti, Ohio, USA
| | - Jeffrey Schellinger
- School of Social Work, College of Allied Health Sciences, University of Cincinnati, Cinainnti, Ohio, USA
| | - Angela Bird
- School of Social Work, College of Allied Health Sciences, University of Cincinnati, Cinainnti, Ohio, USA
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Simmonds KP, Luo Z, Reeves M. Race/Ethnic and Stroke Subtype Differences in Poststroke Functional Recovery After Acute Rehabilitation. Arch Phys Med Rehabil 2021; 102:1473-1481. [PMID: 33684363 DOI: 10.1016/j.apmr.2021.01.090] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Significant racial/ethnic disparities in poststroke function exist, but whether these disparities vary by stroke subtype is unknown. Study goals were to (1) determine if racial/ethnic disparities in the recovery of poststroke function varied by stroke subtype and (2) identify confounding factors associated with these racial/ethnic disparities. DESIGN Secondary analysis of the 1-year Stroke Recovery in Underserved Populations Cohort Study. SETTING Eleven inpatient rehabilitation facilities (IRFs) across the United States. PARTICIPANTS A total of 1066 patients (n=868 with ischemic stroke and n=198 with hemorrhagic stroke, N=1066) who self-identified as White (n=813), Black (n=183), or Hispanic (n=70). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM scores at IRF admission, discharge, 3 months, and 12 months were modeled using multivariable mixed effects longitudinal regression. RESULTS Compared with White patients, Black (-6.1 and -4.6) and Hispanic (-10.1 and -9.9) patients had significantly lower FIM scores at 3 and 12 months, respectively. A significant (P<.01) 3-way interaction (race/ethnic*subtype*time) indicated that disparities varied by stroke subtype. The stroke subtype differences were most prominent for Black-White disparities because disparities in hemorrhagic stroke were present at IRF admission (vs 3 months for ischemic stroke). Additionally, at 12 months, the magnitude of Black-White disparities was over 3 times larger for hemorrhagic stroke (-10.4) than ischemic stroke (-3.1). Age primarily influenced Black-White disparities (especially for hemorrhagic stroke), but factors that influenced Hispanic-White disparities were not identified. Sensitivity analyses showed that there were stroke subtype differences in racial/ethnic disparities for cognitive (but not motor) function, and results were robust to adjustments for missing data because of attrition. CONCLUSIONS There are significant differences between stroke subtypes in the timing and magnitude of Black-White disparities in poststroke function. Age was a major confounding factor for Black-White disparities (particularly for hemorrhagic stroke). Overall, Hispanic patients had the lowest levels of poststroke function, and more work is needed to identify significant factors that influence Hispanic-White disparities.
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Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; DO/PhD Program, College of Osteopathic Medicine, Michigan State University, East Lansing, MI.
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
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Buie JNJ, Zhao Y, Burns S, Magwood G, Adams R, Sims-Robinson C, Lackland DT. Racial Disparities in Stroke Recovery Persistence in the Post-Acute Stroke Recovery Phase: Evidence from the Health and Retirement Study. Ethn Dis 2020; 30:339-348. [PMID: 32346280 PMCID: PMC7186057 DOI: 10.18865/ed.30.2.339] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Blacks have a higher burden of post-stroke disability. Factors associated with racial differences in long-term post-stroke disability are not well-understood. Our aim was to assess the long-term racial differences in risk factors associated with stroke recovery. Methods We examined Health and Retirement Study (HRS) longitudinal interview data collected from adults living with stroke who were aged >50 years during 2000-2014. Analysis of 1,002 first-time, non-Hispanic, Black (210) or White (792) stroke survivors with data on activities of daily living (ADL), fine motor skills (FMS) and gross motor skills (GMS) was conducted. Ordinal regression analysis was used to assess the impact of sex, race, household residents, household income, comorbidities, and the time since having a stroke on functional outcomes. Results Black stroke survivors were younger compared with Whites (69 ± 10.4 vs 75 ± 11.9). The majority (~65%) of Black stroke survivors were female compared with about 54% White female stroke survivors (P=.007). Black stroke survivors had more household residents (P<.001) and comorbidities (P<.001). Aging, being female, being Black and a longer time since stroke were associated with a higher odds of having increased difficulty in ADL, FMS and/or GMS. Comorbidities were associated with increased difficulty with GMS. Black race increased the impact of comorbidities on ADL and FMS in comparison with Whites. Conclusion Our data suggest that the effects of aging, sex and unique factors associated with race should be taken into consideration for future studies of post-stroke recovery and therapy.
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Affiliation(s)
- Joy N. J. Buie
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
| | - Yujing Zhao
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
| | - Suzanne Burns
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- School of Occupational Therapy, Texas Women’s University, Denton, TX
| | - Gayenell Magwood
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- College of Nursing Medical University of South Carolina, Charleston, SC
| | - Robert Adams
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
| | | | | | - WISSDOM Research Center Study Group
- WISSDOM Center, Medical University of South Carolina, Charleston, SC
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
- School of Occupational Therapy, Texas Women’s University, Denton, TX
- College of Nursing Medical University of South Carolina, Charleston, SC
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Gannon B, Tyson SF. Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Therapy is key to effective stroke care, but many patients receive little.
Objectives
To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.
Design
Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.
Setting
Stroke services in England, Wales and Northern Ireland.
Participants
A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.
Results
Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.
Limitations
Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.
Conclusions
Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah F Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Garcia JJ, Warren KL. Race/Ethnicity Matters: Differences in Poststroke Inpatient Rehabilitation Outcomes. Ethn Dis 2019; 29:599-608. [PMID: 31641327 DOI: 10.18865/ed.29.4.599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective To examine racial/ethnic differences in poststroke inpatient rehabilitation outcomes. Design Cross-sectional and retrospective study of administrative data across 2002-2018. Setting An inpatient rehabilitation facility in Southern California. Participants 3,876 racial/ethnic people aged ≥ 18 years. Main Outcome Measures Functional Independence Measure (FIM®) and discharge disposition. Results Participants were non-Hispanic Whites (NHWs, 68.5%), Hispanics (17.1%), non-Hispanic Asians (NHAs, 7.4%), and non-Hispanic Blacks (NHBs, 6.4%) aged 18-102 years (Mage = 68.47±14.66 years; MLOS = 19.47±10.05 days). Above and beyond covariates, multivariate hierarchical regression analyses showed race/ethnicity significantly predicted admission, motor efficiency, and discharge FIM® scores. Compared with NHWs, the Hispanic and NHA groups were associated with lower cognitive, motor, and total FIM® scores at admission; the NHB group was associated with lower motor efficiency, lower discharge motor and total FIM® scores, whereas the Hispanic group was associated with higher discharge total FIM® scores. Lastly, Hispanics had higher odds of a discharge home compared with NHWs. Conclusions Findings suggest racial/ethnic differences exist in poststroke rehabilitation outcomes.
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Affiliation(s)
- James J Garcia
- Department of Psychology, University of La Verne, La Verne, CA and the Department of Neuropsychology and Psychology, Casa Colina Hospital and Centers for Healthcare, Pomona, CA
| | - Karlita L Warren
- Department of Kinesiology, Athletic Training Program, University of La Verne, La Verne, CA
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Scrutinio D, Guida P, Lanzillo B, Ferretti C, Loverre A, Montrone N, Spaccavento S. Rehabilitation Outcomes of Patients With Severe Disability Poststroke. Arch Phys Med Rehabil 2018; 100:520-529.e3. [PMID: 30056158 DOI: 10.1016/j.apmr.2018.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/04/2018] [Accepted: 06/21/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To characterize rehabilitation outcomes of patients with severe poststroke motor impairment (MI) and develop a predictive model for treatment failure. DESIGN Retrospective cohort study. Correlates of treatment failure, defined as the persistence of severe MI after rehabilitation, were identified using logistic regression analysis. Then, an integer-based scoring rule was developed from the logistic model. SETTING Three specialized inpatient rehabilitation facilities. PARTICIPANTS Patients (N=1265) classified as case-mix groups (CMGs) 0108, 0109, and 0110 of the Medicare classification system. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Change in the severity of MI, as assessed by the FIM, from admission to discharge. RESULTS Median FIM-motor (FIM-M) score increased from 17 (interquartile range [IQR] 14-23) to 38 (IQR, 25-55) points. Median proportional recovery, as expressed by FIM-M effectiveness, was 26% (IQR, 12-47). Median FIM-M change was 18 (IQR, 9-34) points. About 38.5% patients achieved the minimal clinically important difference. Eighteen point six percent and 32.0% of the patients recovered to a stage of either mild (FIM-M ≥62) or moderate (FIM-M 38-61) MI, respectively. All between-CMG differences were statistically significant. Outcomes have also been analyzed according to classification systems used in Australia and Canada. The scoring rule had an area under the curve of 0.833 (95% confidence interval, 0.808-0.858). Decision curve analysis displayed large net benefit of using the risk score compared with the treat all strategy. CONCLUSIONS This study provides a snapshot of rehabilitation outcomes in a large cohort of patients with severe poststroke MI, thus filling a gap in knowledge. The scoring rule accurately identified the patients at risk for treatment failure.
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Affiliation(s)
- Domenico Scrutinio
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Cassano Murge, Italy.
| | - Pietro Guida
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Cassano Murge, Italy
| | - Bernardo Lanzillo
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Telese Terme, Italy
| | - Chiara Ferretti
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Montescano, Italy
| | - Anna Loverre
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Cassano Murge, Italy
| | - Nicola Montrone
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Cassano Murge, Italy
| | - Simona Spaccavento
- Istituti Clinici Scientifici Maugeri-SPA SB. I.R.C.C.S., Cassano Murge, Italy
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Burns SP, White BM, Magwood G, Ellis C, Logan A, Jones Buie JN, Adams RJ. Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools. Disabil Rehabil 2018; 41:1835-1845. [PMID: 29569497 DOI: 10.1080/09638288.2018.1448467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.
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Affiliation(s)
- Suzanne Perea Burns
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA
| | - Brandi M White
- b College of Health Sciences , University of Kentucky , Lexington , KY , USA
| | - Gayenell Magwood
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA.,c College of Nursing , Medical University of South Carolina , Charleston , SC , USA
| | - Charles Ellis
- d Department of Communication Sciences and Disorders , East Carolina University , Greenville , NC , USA
| | - Ayaba Logan
- e Department of Library Science and Informatics , Medical University of South Carolina , Charleston , SC , USA
| | - Joy N Jones Buie
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA
| | - Robert J Adams
- a WISSDOM Center , Medical University of South Carolina , Charleston , SC , USA.,f Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
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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 PMCID: PMC5705290 DOI: 10.1161/strokeaha.117.017290] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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Affiliation(s)
- Lesli E Skolarus
- From the Stroke Program, Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.); and Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI (J.F.B.).
| | - Chunyang Feng
- From the Stroke Program, Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.); and Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI (J.F.B.)
| | - James F Burke
- From the Stroke Program, Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.); and Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI (J.F.B.)
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Ellis C, Magwood G, White BM. Racial Differences in Patient-Reported Post-Stroke Disability in Older Adults. Geriatrics (Basel) 2017; 2:geriatrics2020016. [PMID: 31011026 PMCID: PMC6371106 DOI: 10.3390/geriatrics2020016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/24/2017] [Accepted: 05/21/2017] [Indexed: 11/16/2022] Open
Abstract
Longstanding disparities have been reported in stroke-related outcomes with blacks experiencing more post-stroke disabilities. Little is known about long-term disability outcomes among older stroke survivors. This study was a retrospective analysis of data from the 2015 National Health Interview Survey (NHIS). A group of 655 stroke survivors (541 white and 114 black) age 65 and older were asked to rate their ability to complete 10 functional tasks without special equipment. Univariate comparisons were completed using t-tests and chi-square statistics for racial comparisons of disability reports. Multinomial logistic regression was used to determine odds of reporting disability after controlling for relevant covariates. The mean age of the sample was 76.6 years. After controlling for relevant covariates, white stroke survivors were less likely to report the following tasks being "very difficult/can't do at all" without using special equipment compared to blacks: reach overhead (OR = 0.39, 95% CI 0.23⁻0.65; p = 0.000) and grasp small objects (OR = 0.42, 95% CI 0.25⁻0.73; p = 0.002). Both black and white older stroke survivors experience significant post-stroke disability across a range of functional tasks. Slightly greater long term post-stroke disability appears to exist among older blacks.
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Affiliation(s)
- Charles Ellis
- Department of Communication Sciences & Disorders, College of Allied Health Sciences, East Carolina University, 3310H Health Sciences Building, MS 668, Greenville, NC 27834, USA.
| | - Gayenell Magwood
- College of Nursing, Medical University of South Carolina, 97 Jonathan Lucas Ave, Charleston, SC 29425, USA.
| | - Brandi M White
- Division of Healthcare Studies, College of Health Professions, Medical University of South Carolina, 151-B Rutledge Ave, Charleston, SC 29425, USA.
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Inpatient Rehabilitation Outcomes in Patients With Stroke Aged 85 Years or Older. Phys Ther 2016; 96:1381-8. [PMID: 26916929 DOI: 10.2522/ptj.20150364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 02/13/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the United States, people 85 years of age or older have a growing number of strokes each year, and this age group is most at risk for disability. Inpatient rehabilitation facilities (IRFs) adhere closest to post-acute stroke rehabilitation guidelines and have the most desirable outcomes compared with skilled nursing facilities. As stroke is one of the leading causes of disability, knowledge of postrehabilitation outcomes is needed for this age group, although at present such information is limited. OBJECTIVE The purpose of this study was to describe functional and discharge outcomes after IRF rehabilitation in people with stroke aged 85 years or older. DESIGN A serial, cross-sectional design was used. METHODS Inpatient Rehabilitation Facility-Patient Assessment Instrument data were analyzed beginning in 2002 for the first 5.5 years after implementation of the prospective payment system and included 71,652 cases. Discharge function, measured using the Functional Independence Measure (FIM), and community discharge were the discharge outcome measures. Sample description used frequencies and means. Generalized estimating equations (GEEs) with post hoc testing were used to analyze the annual trends for discharge FIM and community discharge by age group (85-89, 90-94, 95-99, and ≥100 years). Risk-adjusted linear and logistic GEE models, with control for cluster, were used to analyze the association between both outcome measures and age group. RESULTS Over 5.5 years, mean discharge FIM scores decreased by 3.6 points, and mean achievement of community discharge decreased 5.5%. Approximately 54% of the sample achieved community discharge. Continuous and logistic GEEs revealed factors associated with discharge outcomes. LIMITATIONS Results obtained using an observational design should not be viewed as indicating causation. The lack of control for a caregiver may have altered results. CONCLUSIONS The very elderly people admitted to IRF stroke rehabilitation made functional gains, and most were able to return to the community.
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Cary MP, Merwin EI, Oliver MN, Williams IC. Inpatient Rehabilitation Outcomes in a National Sample of Medicare Beneficiaries With Hip Fracture. J Appl Gerontol 2016; 35:62-83. [PMID: 25037153 PMCID: PMC4537688 DOI: 10.1177/0733464814541325] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/01/2014] [Indexed: 12/30/2022] Open
Abstract
Effects of patient characteristics on rehabilitation outcomes (functional status at discharge, discharged home) were assessed in a retrospective study of Medicare beneficiaries admitted to Medicare-certified inpatient rehabilitation facilities (IRFs) following hospitalization for hip fracture in 2009 (N = 34,984). Hierarchical regression analysis showed significantly higher functional status at discharge (p < .0001) for patients with these characteristics: White or Asian, younger, female, lived alone, higher functional status at admission, fewer comorbidities, no tier comorbidities, and longer IRF length of stay (LOS). Likelihood of discharged home was higher for patients with these characteristics: Hispanic (1.49 [1.32, 1.68]), Asian (1.35 [1.04, 1.74]), or Black (1.28 [1.12, 1.47]); younger (0.96 [0.96, 0.96]); female (1.14 [1.08, 1.20]); lived with others (2.12 [2.01, 2.23]); higher functional status at admission (1.06 [1.06, 1.06]); fewer comorbidities, no tier comorbidities; and longer LOS (1.61 [1.56, 1.67]). Functional status at admission, tier comorbidities, and race/ethnicity contributed the most to variance in functional status at discharge. Living with others contributed the most to variance in discharged home.
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Ellis C, Boan AD, Turan TN, Ozark S, Bachman D, Lackland DT. Racial Differences in Poststroke Rehabilitation Utilization and Functional Outcomes. Arch Phys Med Rehabil 2015; 96:84-90. [DOI: 10.1016/j.apmr.2014.08.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/26/2014] [Accepted: 08/27/2014] [Indexed: 11/29/2022]
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Racial/Ethnic differences in poststroke rehabilitation outcomes. Stroke Res Treat 2014; 2014:950746. [PMID: 25028619 PMCID: PMC4084586 DOI: 10.1155/2014/950746] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/22/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Significant racial and ethnic disparities in stroke incidence, severity, and morbidity have been consistently reported; however, less is known about potential differences in poststroke rehabilitation outcomes. Objective. To examine racial and ethnic differences in poststroke rehabilitation outcomes. Methods. We completed an in-depth search of Medline and several major journals dedicated to publishing research articles on stroke, rehabilitation, and racial-ethnic patterns of disease over a 10-year period (2003–2012). We identified studies that reported rehabilitation outcomes and the race or ethnicity of at least two groups. Results. 17 studies involving 429,108 stroke survivors met inclusion criteria for the review. The majority (94%) of studies examined outcomes between Blacks and Whites. Of those studies examining outcomes between Blacks and Whites, 59% showed that Blacks were generally less likely to achieve equivalent functional improvement following rehabilitation. Blacks were more likely to experience lower FIM gain or change scores (range: 1–60%) and more likely to have lower efficiency scores (range: 5–16%) than Whites. Conclusions. Black stroke survivors appear to generally achieve poorer functional outcomes than White stroke survivors. Future studies are warranted to evaluate the precise magnitude of these differences, whether they go beyond chance, and the underlying contributory mechanisms.
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Shorter length of stay is associated with worse functional outcomes for medicare beneficiaries with stroke. Phys Ther 2013; 93:1592-602. [PMID: 23886846 DOI: 10.2522/ptj.20120484] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Understanding of the potential impact that length of stay (LOS) may have on Medicare beneficiaries' poststroke discharge function and discharge destination since implementation of a prospective payment system is lacking. OBJECTIVE This study examined the trends and associations between LOS and discharge outcomes in Medicare beneficiaries with stroke treated in inpatient rehabilitation facilities (IRFs). DESIGN A serial, cross-sectional analysis of the Inpatient Rehabilitation Facility Patient Assessment Instrument dataset was conducted. The sample consisted of 371,211 patients with stroke who were over 65 years of age in all IRFs in the United States between January 1, 2002, and June 30, 2007. METHODS Annual trends for means of LOS, admission and discharge Functional Independence Measure (FIM) scores, and percent community discharge were examined using generalized estimating equations (GEEs) with facility level control and post hoc testing. The association between discharge FIM scores and LOS was examined using a continuous, multivariate GEE model. The association between community discharge and LOS was examined using a logistic, multivariate GEE model. RESULTS Time trends showed mean LOS decreased 1.8 days; admission and discharge FIM scores declined 4.4 points and 3.6 points, respectively; and mean community discharges declined 5.4%. Controlling for study year and covariates, each day was associated with an increase of 0.50 discharge FIM points (95% confidence interval=0.48, 0.52). Each day also was associated with a 0.3% decrease in odds of community discharge (95% confidence interval=0.994, 0.999). LIMITATIONS Reliability and validity of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) are lacking. Results may have been biased by a lack of control at the patient and facility levels. CONCLUSIONS Medicare beneficiaries with stroke treated in IRFs experienced shorter LOS, had worsening admission and discharge function, and had fewer community discharges. Worsening admission function and shorter LOS may contribute to worsening discharge outcomes, which may indicate a lack of readiness for IRF treatment and that facility-level factors may be playing a role in shorter LOS.
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Physical therapy activities in stroke, knee arthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes. Phys Ther 2011; 91:1826-37. [PMID: 22003165 PMCID: PMC3229046 DOI: 10.2522/ptj.20100424] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown. OBJECTIVE The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups. DESIGN This was a prospective observational cohort study. METHODS The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities. RESULTS All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome. LIMITATIONS The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities. CONCLUSIONS All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.
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Deutscher D, Horn SD, Smout RJ, DeJong G, Putman K. Black-white disparities in motor function outcomes taking into account patient characteristics, nontherapy ancillaries, therapy activities, and therapy interventions. Arch Phys Med Rehabil 2010; 91:1722-30. [PMID: 21044717 DOI: 10.1016/j.apmr.2010.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 08/06/2010] [Accepted: 08/09/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions. DESIGN Multicenter prospective observational cohort study of poststroke rehabilitation. SETTING Six U.S. inpatient rehabilitation facilities. PARTICIPANTS Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104-107 for moderate strokes [n=397], CMGs 108-114 for severe strokes [n=335]). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Discharge Motor FIM. RESULTS Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R(2)) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R(2) to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes. CONCLUSIONS After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke.
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Affiliation(s)
- Daniel Deutscher
- Physical Therapy Services, Maccabi Healthcare Services-HMO, Tel-Aviv, Israel.
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