Race, Marital History, and Risks for Stroke in US Older Adults

Factors associated with racial differences in all-cause 30-day readmission in adults with cardiovascular disease: an observational study of a large healthcare system

OBJECTIVE

To examine factors contributing to racial differences in 30-day readmission in patients with cardiovascular disease (CVD).

DESIGN

Patients were enrolled from 1 January 2015 to 31 August 2017 and data were collected from electronic health records and a standardised interview administered prior to discharge.

SETTING

Duke Heart Center in the Duke University Health System.

PARTICIPANTS

Patients aged 18 and older admitted for the treatment of cardiovascular-related conditions (n=734).

MAIN OUTCOME AND MEASURES

All-cause readmission within 30 days was the main outcome. Multivariate logistic regression models were used to examine whether and to what extent socioeconomic, psychosocial, behavioural and healthcare-related factors contributed to 30-day readmissions in Black and White CVD patients.

RESULTS

The median age of patients was 66 years and 18.1% (n=133) were readmitted within 30 days after discharge. Black patients were more likely than White patients to be readmitted (OR 1.62; 95% CI 1.18 to 2.23) and the racial difference in readmissions was largely reduced after taking into account differences in a wide range of clinical and non-clinical factors (OR 1.37; 95% CI 0.98 to 1.91). In Black patients, readmission risks were especially high in those who were retired (OR 3.71; 95% CI 1.71 to 8.07), never married (OR 2.21; 95% CI 1.21 to 4.05), had difficulty accessing their routine care (OR 2.88; 95% CI 1.70 to 4.88) or had been hospitalised in the prior year (OR 1.97; 95% CI 1.16 to 3.37). In White patients, being widowed (OR 2.39; 95% CI 1.41 to 4.07) and reporting a higher number of depressive symptoms (OR 1.07; 95% CI 1.00 to 1.13) were the key factors associated with higher risks of readmission.

CONCLUSIONS AND RELEVANCE

Black patients were more likely than White patients to be readmitted within 30 days after hospitalisation for CVD. The factors contributing to readmission differed by race and offer important clues for identifying patients at high risk of readmission and tailoring interventions to reduce these risks.

Epidemiological characterization of stroke cases under rehabilitation on the Brazilian Unified Health System in Mossoró, Rio Grande do Norte

Objectives: To identify the clinical and epidemiological characteristics of patients undergoing treatment for a stroke at the only public rehabilitation clinic in Mossoró/RN (Doctor Ozias Alves de Souza Rehabilitation Center). Methods: Quantitative, prospective, descriptive, cross-sectional, exploratory study, structured from responses to a clinical-epidemiological and sociodemographic questionnaire with 39 items, to assess aspects concerning the profile of patients affected by stroke and undergoing rehabilitation treatment. Results: Twenty-eight individuals with stroke sequelae undergoing treatment at the rehabilitation center were identified, whose clinical-epidemiological characteristics revealed equivalence concerning gender (50% male:female), the predominance of white and brown color/race (46.4% each), and overweight (35.7%). Most of the patients lived in a family environment with a spouse (64.3%), were retired (71.4%), with monthly income between one and two minimum wages (64.3%), with hemiplegic sequelae resulting from the stroke (85.7%) and difficulties in adapting to the current way of life (75%). Conclusion: The present study allows an initial scrutiny of stroke cases in Mossoró/RN and their rehabilitation process. Such data may contribute to a better understanding of issues concerning stroke by government sectors, aiming to improve care and multidisciplinary interventions to provide patients with reinsertion in both work practice and in everyday social relationships.

Period Trends in Self-Rated Health at Midlife: Variations by Race/Ethnicity, Union Status, and Education

BACKGROUND

Research shows rising midlife morbidity among US non-Hispanic white adults, but it is unclear if and how self-rated health of racial/ethnic minority adults has changed in recent years. More research is also needed to understand factors moderating self-rated health trends among middle-aged white adults. Given the racial/ethnic and educational differences in family experiences in recent decades, scholars have called for analysis of union status and educational differentials in self-rated health trends across racial/ethnic groups.

METHODS

We used data from 2000-2018 National Health Interview Survey to analyze racial/ethnic variations in self-rated health trends at midlife across union status and educational groups.

RESULTS

The findings showed that recent trends in self-rated health differed not just by race/ethnicity, but also by union status and education. Changes in self-rated health were more pronounced among non-Hispanic white men and women than among racial/ethnic minorities. However, not all groups of middle-aged white adults experienced self-rated health decline. Also, worsening self-rated health at midlife extends to some nonwhites. Compared to the health decline among many racial/ethnic/gender and educational groups, married black women with college degree or higher reported significant improvement in their self-rated health over time.

CONCLUSION

The findings demonstrate the interactions among race/ethnicity, gender, union status, and education in recent self-rated health trends.

Marital loss and risk of dementia: Do race and gender matter?

Recent studies have found that marital loss through divorce or widowhood is associated with a higher risk of dementia for older adults. However, whether these associations vary by race and gender is less clear. To address this gap, we drew upon longitudinal data from the Health and Retirement Study (2000-2016) to investigate the association between marital loss and dementia risk, separately for non-Hispanic Whites and non-Hispanic Blacks. We further examined gender variations in the link between marital loss and dementia risk within each racial group. Results from discrete-time event history models suggested that widowhood is significantly associated with a higher risk of dementia for both Whites and Blacks, controlling for basic demographic characteristics. However, while divorce is significantly associated with a higher risk of dementia for Blacks, the association is marginally significant (p < 0.1) for Whites. There are few significant gender variations in these associations except for the effect of divorce among Whites. Even after controlling for economic and health-related factors, we found that divorce is associated with a higher risk of dementia among White men but not among White women. Economic resources explain a significant portion of the association between widowhood and dementia risk, more so for Whites than for Blacks. Our findings call for more research into the pathways through which marital loss shapes the risk of dementia across racial and ethnic groups.

Family Matters: Research on Family Ties and Health, 2010-2020

Family ties have wide-ranging consequences for health, for better and for worse. This decade review uses a life course perspective to frame significant advances in research on the effects of family structure and transitions (e.g., marital status), and family dynamics and quality (e.g., emotional support from family members), on health across the life course. Significant advances include the linking of childhood family experiences to health at older ages, identification of biosocial processes that explain how family ties influence health throughout life, research on social contagion showing how family members influence one another's health, and attention to diversity in family and health dynamics, including gender, sexuality, socioeconomic, and racial diversity. Significant innovations in methods include dyadic and family-level analysis and causal inference strategies. The review concludes by identifying directions for future research on families and health, advocating for a "family biography" framework to guide future research, and calling for more research specifically designed to assess policies that affect families and their health from childhood into later life.

Married, unmarried, divorced, and widowed and the risk of stroke

OBJECTIVES

Most studies report that marriage carries a lower risk of stroke than single living. Whether the marriage advantage is applicable with respect to all other marital status categories (unmarried, divorced, widow) remains unclear. We studied marital status and its association with incident stroke.

MATERIAL AND METHODS

We included all patients > 40 years of age admitted to hospital for stroke in Denmark during 2003-2012 and compared marital status to the general Danish population (5.5 millions). Relative risks (RR) for stroke were estimated in log-linear Poisson regression models adjusting for age, sex, calendar year, income, and length of education.

RESULTS

A total of 58 847 patients with incident stroke were included. Crude incidence rates of stroke (per 1000 per year) among the four marital status categories were as follows: 1.96 (married), 1.52 (unmarried), 2.36 (divorced), and 5.43 (widowed). Compared to married persons, adjusted risk of stroke was significantly increased for divorced (RR 1.23; CI 1.19-1.27) and unmarried men (RR 1.07; CI 1.03-1.11) but not for widowed men (RR 1.02; CI 0.98-1.06); risk was slightly increased for divorced women (RR 1.10; CI 1.06-1.15) while not for widowed (RR 1.0; CI 0.97-1.03) and unmarried women (RR 0.97; CI 0.97-1.03).

CONCLUSIONS

Divorce was associated with higher risk of stroke, especially in men. Living in marriage or as unmarried or widower had only little or no impact on the risk of stroke.

Race Differences in Linking Family Formation Transitions to Women's Mortality

We examine how the timing and sequencing of first marriage and childbirth are related to mortality for a cohort of 4,988 white and black women born between 1922 and 1937 from the National Longitudinal Survey of Mature Women. We use Cox proportional hazard models to estimate race differences in the association between family formation transitions and mortality. Although we find no relationships between marital histories and longevity, we do find that having children, the timing of first birth, and the sequencing of childbirth and marriage are associated with mortality. White women who had children lived longer than those who had none, but the opposite was found for black women. The effects of birth timing also differed by race; delaying first birth to older ages was protective for white women but not black women. These results underscore the importance of social context in the study of life course transitions.

Racial Differences in Patient-Reported Post-Stroke Disability in Older Adults

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.

Marital History and Survival After Stroke

BACKGROUND

Stroke is among the leading causes of disability and death in the United States, and nearly 7 million adults are currently alive after experiencing a stroke. Although the risks associated with having a stroke are well established, we know surprisingly little about how marital status influences survival in adults with this condition. This study is the first prospective investigation of how marital history is related to survival after stroke in the United States.

METHODS AND RESULTS

Data from a nationally representative sample of older adults who experienced a stroke (n=2351) were used to examine whether and to what extent current marital status and past marital losses were associated with risks of dying after the onset of disease. Results showed that the risks of dying following a stroke were significantly higher among the never married (hazard ratio [HR], 1.71; 95% CI, 1.31–2.24), remarried (HR, 1.23; 95% CI, 1.06–1.44), divorced (HR, 1.23; 95% CI, 1.01–1.49), and widowed (HR, 1.25; 95% CI, 1.10–1.43) relative to those who remained continuously married. We also found that having multiple marital losses was especially detrimental to survival-regardless of current marital status and accounting for multiple socioeconomic, psychosocial, behavioral, and physiological risk factors.

CONCLUSIONS

Marital history is significantly associated with survival after stroke. Additional studies are needed to further examine the mechanisms contributing to the associations and to better understand how this information can be used to personalize care and aggressively treat vulnerable segments of the population.

Marital history and survival after a heart attack

Heart disease is the leading cause of death in the United States and nearly one million Americans will have a heart attack this year. Although the risks associated with a heart attack are well established, we know surprisingly little about how marital factors contribute to survival in adults afflicted with heart disease. This study uses a life course perspective and longitudinal data from the Health and Retirement Study to examine how various dimensions of marital life influence survival in U.S. older adults who suffered a heart attack (n = 2197). We found that adults who were never married (odds ratio [OR] = 1.73), currently divorced (OR = 1.70), or widowed (OR = 1.34) were at significantly greater risk of dying after a heart attack than adults who were continuously married; and the risks were not uniform over time. We also found that the risk of dying increased by 12% for every additional marital loss and decreased by 7% for every one-tenth increase in the proportion of years married. After accounting for more than a dozen socioeconomic, psychosocial, behavioral, and physiological factors, we found that current marital status remained the most robust indicator of survival following a heart attack. The implications of the findings are discussed in the context of life course inequalities in chronic disease and directions for future research.