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Jones Berkeley SB, Johnson AM, Mormer ER, Ressel K, Pastva AM, Wen F, Patterson CG, Duncan PW, Bushnell CD, Zhang S, Freburger JK. Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010026. [PMID: 38189125 PMCID: PMC10997162 DOI: 10.1161/circoutcomes.123.010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/13/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral. METHODS We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10 702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral. RESULTS Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained. CONCLUSIONS One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
- Sara B Jones Berkeley
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Elizabeth R Mormer
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Kristin Ressel
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Amy M Pastva
- Department of Orthopaedic Surgery, Doctor of Physical Therapy Division and Center for the Study of Aging and Human Development, Duke University School of Medicine (A.M.P.)
| | - Fang Wen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Charity G Patterson
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | | | - Shuqi Zhang
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
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Exploring discharge destination following severe stroke. BRAIN IMPAIR 2020. [DOI: 10.1017/brimp.2020.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Patients with severe stroke frequently present with substantial impairments but are often not prioritised for post-discharge rehabilitation. There is a need to determine where these patients are discharged to in order to facilitate appropriate allocation of post-discharge pathway resources.Aim:The present study aimed to describe the discharge pathways of patients with severe stroke and to identify predictors of discharge destination for these patients.Method:A descriptive, retrospective design was utilised to determine the discharge destination for 770 patients with severe stroke in Queensland, Australia. Binomial logistic regression was used to determine the variables that predicted discharge destination.Results:The results indicated that 58.44% of patients were discharged home (n = 450). Age, length of stay, discharge ward and geographical region emerged as significant predictors of discharge destination. The full model containing all predictors was statistically significant and, as a whole, explained 36.50% of the variance in discharge destination.Conclusion:These results highlight the importance of these variables in influencing the outcomes of patients with severe stroke, which may assist post-hospital discharge services in allocating resources for patients with severe stroke.
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Roth DL, Sheehan OC, Huang J, Rhodes JD, Judd SE, Kilgore M, Kissela B, Bettger JP, Haley WE. Medicare claims indicators of healthcare utilization differences after hospitalization for ischemic stroke: Race, gender, and caregiving effects. Int J Stroke 2016; 11:928-934. [PMID: 27435204 DOI: 10.1177/1747493016660095] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.
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Affiliation(s)
- David L Roth
- 1 Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA
| | - Orla C Sheehan
- 1 Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jin Huang
- 1 Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA
| | - James D Rhodes
- 2 Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne E Judd
- 2 Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Meredith Kilgore
- 3 Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brett Kissela
- 4 Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | | | - William E Haley
- 6 School of Aging Studies, University of South Florida, Tampa, FL, USA
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iScore for predicting institutional care after ischemic stroke: a population-based study. J Stroke Cerebrovasc Dis 2015; 24:694-8. [PMID: 25601174 DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/31/2014] [Accepted: 11/14/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We assessed whether the iScore could predict the need for poststroke institutional care. METHODS Patients with acute ischemic stroke living in Dijon, France, were recorded between 2006 and 2011, using a population-based stroke registry. The iScore was calculated for each patient. A logistic regression model was used to assess the performance of the iScore for predicting the need for placement in a care institution. The discrimination and calibration of the model were assessed using the c statistic and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS Of the 1199 patients recorded, 124 were excluded because of early death and 95 because of missing for variables included in the iScore. Of the remaining 980 patients, 522 (53.3%) returned home and 458 (46.7%) required placement in a care institution. The median iScore was 123 (interquartile range, 97-148), and the proportion of patients who required placement in a care institution increased with each quintile of risk score. The discrimination of the model was good with a c statistic of .75 (95% confidence interval, .72-.78), as was calibration (P = .35). CONCLUSIONS The iScore could be useful for predicting the need for placement in a care institution in ischemic stroke patients. Further studies are required to confirm this finding.
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Van der Cruyssen K, Vereeck L, Saeys W, Remmen R. Prognostic factors for discharge destination after acute stroke: a comprehensive literature review. Disabil Rehabil 2014; 37:1214-27. [DOI: 10.3109/09638288.2014.961655] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jan S, Essue BM, Glozier N, Lindley R, Li Q, Hackett ML. Are rehabilitation services following stroke accessed equitably in Australia?: findings from the psychosocial outcomes in stroke (POISE) cohort study. BMC Public Health 2013; 13:884. [PMID: 24063593 PMCID: PMC3851188 DOI: 10.1186/1471-2458-13-884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 09/03/2013] [Indexed: 11/24/2022] Open
Abstract
Background Stroke recovery is generally optimised through the provision of multidisciplinary rehabilitation. However not much is known about how equitably such services are utilised. This study examines the determinants of physiotherapy and speech therapy utilisation in rehabilitation within a cohort of young stroke survivors in Australia. Methods Psychosocial Outcomes in StrokE (POISE) was a three-year prospective observational study involving stroke survivors between the ages of 18 and 65 years recruited within 28 days of stroke. It was conducted in 20 stroke units in Australia. Participants were interviewed at 28 days (baseline), 6 and 12 months after stroke about their demographic and socioeconomic background, economic and health outcomes and the use of services. The primary outcome in this paper is utilisation of rehabilitation in the 12 months after stroke. Results Of 414 participants, 254 (61%) used some rehabilitation in the 12 months post stroke. The strongest predictor of use of these rehabilitation services was dependency at 28 days, as assessed by need for assistance in activities of daily living (OR=33.1; p<0.0001). Other significant variables were two dimensions of social capital - an individuals’ ability to make important decisions, which had a negative relationship (OR = 0.43; p=0.04) and number of close friends (OR= 1.042; p=0.02). Conclusion These findings demonstrate that socio-demographic factors exert little influence on the use of rehabilitation services in working age stroke patients and that the use of such services is primarily determined by 'need’. Such findings suggest that services are being provided equitably. Trial registration ANZCTRN12608000459325
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Affiliation(s)
- Stephen Jan
- The George Institute for Global Health, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia.
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Béjot Y, Troisgros O, Gremeaux V, Lucas B, Jacquin A, Khoumri C, Aboa-Eboulé C, Benaïm C, Casillas JM, Giroud M. Poststroke Disposition and Associated Factors in a Population-Based Study. Stroke 2012; 43:2071-7. [DOI: 10.1161/strokeaha.112.658724] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The organization of poststroke care will be a major challenge in coming years. We aimed to assess hospital disposition after stroke and its associated factors in clinical practice.
Methods—
All cases of stroke from 2006 to 2010 were identified from the population-based Stroke Registry of Dijon, France. Demographic features, risk factors, and prestroke treatments were recorded. Admission stroke severity was assessed using the National Institutes of Health Stroke Scale score. At discharge, we collected dementia, disability using the modified Rankin Scale, length of stay, and hospital disposition (home, rehabilitation, convalescent home, and nursing home). Multivariate analyses were performed using logistic regression models to identify associated factors of postdischarge disposition.
Results—
Of the patients with 1069 stroke included, 913 survived acute care. Among them, 433 (47.4%) returned home, whereas 206 (22.6%) were discharged to rehabilitation, 134 (14.7%) were admitted to a convalescent home, and 140 (15.3%) to a nursing home. Old patients, those under anticoagulants before stroke, those with severe stroke on admission, severe disability at discharge, dementia, or prolonged length of stay were less likely to return home. Moreover, advanced age, severe initial stroke, severe disability at discharge, and dementia were associated with admission to convalescent and nursing homes rather than rehabilitation centers.
Conclusion—
This population-based study demonstrated that postdischarge destinations are associated with several factors. Our findings may be useful to establish health policy concerning the organization of poststroke care.
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Affiliation(s)
- Yannick Béjot
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Odile Troisgros
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Vincent Gremeaux
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Brigitte Lucas
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Agnès Jacquin
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Catia Khoumri
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Corine Aboa-Eboulé
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Charles Benaïm
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Jean-Marie Casillas
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
| | - Maurice Giroud
- From the Dijon Stroke Registry (Y.B., A.J., C.K., C.A.-E., M.G.), EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France; the Department of Rehabilitation (O.T., V.G., C.B., J.-M.C.), University Hospital of Dijon, Dijon, France; and the Department of Rehabilitation (B.L.), Divio Hospital, Dijon, France
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Holmes GM, Freburger JK, Ku LJE. Decomposing racial and ethnic disparities in the use of postacute rehabilitation care. Health Serv Res 2011; 47:1158-78. [PMID: 22172017 DOI: 10.1111/j.1475-6773.2011.01363.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the degree to which racial and ethnic disparities in the use of postacute rehabilitation care (PARC) are explained by observed characteristics. DATA SOURCES State inpatient databases (SIDs) for 2005 and 2006 from four diverse states were used to identify patients with stays for joint replacement, stroke, or hip fracture. STUDY DESIGN Our primary outcomes were use of institutional PARC (versus discharge home) and, conditional on discharge to an institution, skilled nursing facility (versus inpatient rehabilitation facility) care. We modified the Oaxaca-Blinder decomposition method to account for the dichotomous outcome and multilevel nature of the data. DATA COLLECTION/EXTRACTION METHODS Discharges from the four SIDs were included if the principal diagnosis (stroke, hip fracture) or procedure (joint replacement) was in the sample inclusion criteria. PRINCIPAL FINDINGS Observed characteristics explained roughly half of the unadjusted differences in use of institutional PARC. Patient-level factors (clinical, age) were more explanatory of disparities in institutional PARC use, while hospital-level factors were more explanatory of skilled nursing facility versus inpatient rehabilitation facility care. CONCLUSIONS Adjustment for characteristics influencing PARC use both mitigated and exacerbated racial/ethnic disparities in use. The degree to which the characteristics explained the disparity varied across conditions and outcomes.
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Affiliation(s)
- George M Holmes
- Department of Health Policy & Management, Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC 27599, USA.
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Hakkennes SJ, Brock K, Hill KD. Selection for Inpatient Rehabilitation After Acute Stroke: A Systematic Review of the Literature. Arch Phys Med Rehabil 2011; 92:2057-70. [DOI: 10.1016/j.apmr.2011.07.189] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 07/03/2011] [Accepted: 07/12/2011] [Indexed: 01/04/2023]
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Freburger JK, Holmes GM, Ku LJE, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases. Arch Phys Med Rehabil 2011; 92:1220-9. [PMID: 21807141 PMCID: PMC4332528 DOI: 10.1016/j.apmr.2011.03.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 02/23/2011] [Accepted: 03/20/2011] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke. DESIGN Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases. SETTING All short-term acute-care hospitals in 4 demographically and geographically diverse states. PARTICIPANTS Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES (1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply. RESULTS Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location. CONCLUSIONS Several sociodemographic and geographic disparities in PARC use were identified.
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Affiliation(s)
- Janet K Freburger
- Cecil G. Sheps Center for HealthServices Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599-7590, USA.
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Cruz-Flores S, Rabinstein A, Biller J, Elkind MSV, Griffith P, Gorelick PB, Howard G, Leira EC, Morgenstern LB, Ovbiagele B, Peterson E, Rosamond W, Trimble B, Valderrama AL. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:2091-116. [PMID: 21617147 DOI: 10.1161/str.0b013e3182213e24] [Citation(s) in RCA: 343] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Our goal is to describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research. In addition, we seek to determine the state of knowledge on the main factors that may explain disparities in stroke care, with the goal of identifying gaps in knowledge to guide future research. The intended audience includes physicians, nurses, other healthcare professionals, and policy makers. METHODS Members of the writing group were appointed by the American Heart Association Stroke Council Scientific Statement Oversight Committee and represent different areas of expertise in relation to racial-ethnic disparities in stroke care. The writing group reviewed the relevant literature, with an emphasis on reports published since 1972. The statement was approved by the writing group; the statement underwent peer review, then was approved by the American Heart Association Science Advisory and Coordinating Committee. RESULTS There are limitations in the definitions of racial and ethnic categories currently in use. For the purpose of this statement, we used the racial categories defined by the US federal government: white, black or African American, Asian, American Indian/Alaskan Native, and Native Hawaiian/other Pacific Islander. There are 2 ethnic categories: people of Hispanic/Latino origin or not of Hispanic/Latino origin. There are differences in the distribution of the burden of risk factors, stroke incidence and prevalence, and stroke mortality among different racial and ethnic groups. In addition, there are disparities in stroke care between minority groups compared with whites. These disparities include lack of awareness of stroke symptoms and signs and lack of knowledge about the need for urgent treatment and the causal role of risk factors. There are also differences in attitudes, beliefs, and compliance among minorities compared with whites. Differences in socioeconomic status and insurance coverage, mistrust of the healthcare system, the relatively limited number of providers who are members of minority groups, and system limitations may contribute to disparities in access to or quality of care, which in turn might result in different rates of stroke morbidity and mortality. Cultural and language barriers probably also contribute to some of these disparities. Minorities use emergency medical services systems less, are often delayed in arriving at the emergency department, have longer waiting times in the emergency department, and are less likely to receive thrombolysis for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded. Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer functional status than whites. Minorities are inadequately treated with both primary and secondary stroke prevention strategies compared with whites. Sparse data exist on racial-ethnic disparities in access to surgical care after intracerebral hemorrhage and subarachnoid hemorrhage. Participation of minorities in clinical research is limited. Barriers to participation in clinical research include beliefs, lack of trust, and limited awareness. Race is a contentious topic in biomedical research because race is not proven to be a surrogate for genetic constitution. CONCLUSIONS There are limitations in the current definitions of race and ethnicity. Nevertheless, racial and ethnic disparities in stroke exist and include differences in the biological determinants of disease and disparities throughout the continuum of care, including access to and quality of care. Access to and participation in research is also limited among minority groups. Acknowledging the presence of disparities and understanding the factors that contribute to them are necessary first steps. More research is required to understand these differences and find solutions.
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Craig BM, Bell BA, Quinn GP, Vadaparampil ST. Prevalence of cancer visits by physician specialty, 1997-2006. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2010; 25:548-555. [PMID: 20336400 PMCID: PMC3811914 DOI: 10.1007/s13187-010-0100-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 02/15/2010] [Indexed: 05/29/2023]
Abstract
Understanding the prevalence of cancer-related visits by physician specialty may help target educational and quality improvement initiatives. Using the 1997-2006 National Ambulatory Medical Care Survey, adult ambulatory visits (N = 161,278) were classified by cancer diagnosis and patients' characteristics and compared with physician specialty. The prevalence of cancer visits within each specialty varied from 0% to 62%. Aside from hematology/oncology (hem/onc) specialties, nine surgical specialties and four medical specialties had more than 1% cancer visits. Cancer patients with private insurance or Medicaid coverage were less likely to see hem/onc specialists compared to Medicare patients. Whereas hem/onc specialists primarily see cancer patients, general surgeons and primary care physicians provide a large amount of cancer services, particularly to underinsured patients. Thus, when trying to contact cancer patients or their physicians, health administrators, researchers, and practitioners should consider targeting general surgeons and primary care physicians in addition to hem/onc specialists.
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Affiliation(s)
- Benjamin M Craig
- Moffitt Cancer Center, 12902 Magnolia Drive, MRC-CANCONT, Tampa, FL 33612-9416, USA.
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Ellis C, Zhao Y, Egede LE. Racial/Ethnic Disparities in Poststroke Outpatient Rehabilitation Among Veterans. J Natl Med Assoc 2010; 102:817-22. [DOI: 10.1016/s0027-9684(15)30679-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Putman K, Horn S, Smout R, Dejong G, Deutscher D, Tian W, Hsieh CH. Racial disparities in stroke functional outcomes upon discharge from inpatient rehabilitation facilities. Disabil Rehabil 2010; 32:1604-11. [DOI: 10.3109/09638281003611078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Koen Putman
- Department of Medical Sociology and Health Sciences, Vrije Universiteit Brussel, Belgium
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington DC, USA
| | - Susan Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | - Randall Smout
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | - Gerben Dejong
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington DC, USA
| | - Daniel Deutscher
- Physical Therapy Service, Maccabi Healthcare Services - HMO, Tel Aviv, Israel
| | - Wenqiang Tian
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington DC, USA
| | - Ching-Hui Hsieh
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington DC, USA
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Chan L, Wang H, Terdiman J, Hoffman J, Ciol MA, Lattimore BF, Sidney S, Quesenberry C, Lu Q, Sandel ME. Disparities in Outpatient and Home Health Service Utilization Following Stroke: Results of a 9-Year Cohort Study in Northern California. PM R 2009; 1:997-1003. [DOI: 10.1016/j.pmrj.2009.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 09/25/2009] [Accepted: 09/26/2009] [Indexed: 11/25/2022]
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16
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Ellis C, Egede LE. Racial/ethnic differences in poststroke rehabilitation utilization in the USA. Expert Rev Cardiovasc Ther 2009; 7:405-10. [PMID: 19379064 DOI: 10.1586/erc.09.6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Longstanding racial/ethnic disparities exist in the USA in the areas of healthcare access, healthcare utilization and health-related outcomes of chronic health conditions, such as stroke. Regarding stroke specifically, significant racial/ethnic disparities in stroke incidence, severity and outcomes have been reported. Despite these differences, little attention has been given to potential racial/ethnic differences in the utilization of rehabilitation services for patients after stroke. To date, only a few studies have been specifically designed to examine racial/ethnic differences in rehabilitation service utilization. A review of these studies and related studies suggests that racial/ethnic differences may be present in the utilization of poststroke rehabilitation services. Consequently, new studies are needed to delineate how race/ethnicity influences utilization of poststroke rehabilitation services and to determine how a reduction in this disparity gap could improve stroke-related outcomes among racial/ethnic minorities in the USA.
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Affiliation(s)
- Charles Ellis
- Charleston VA REAP, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
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17
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Disparities in Postacute Stroke Rehabilitation Disposition to Acute Inpatient Rehabilitation vs. Home. Am J Phys Med Rehabil 2009; 88:100-7. [DOI: 10.1097/phm.0b013e3181951762] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Sandel ME, Wang H, Terdiman J, Hoffman JM, Ciol MA, Sidney S, Quesenberry C, Lu Q, Chan L. Disparities in stroke rehabilitation: results of a study in an integrated health system in northern California. PM R 2009; 1:29-40. [PMID: 19627870 PMCID: PMC3432287 DOI: 10.1016/j.pmrj.2008.10.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 10/24/2008] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether there are disparities in postacute stroke rehabilitation based on type of stroke, race/ethnicity, sex/gender, age, socioeconomic status, geographic region, or service area referral patterns in a large integrated health system with multiple levels of care. DESIGN Cohort study tracking rehabilitation services for 365 days after acute hospitalization for a first stroke. SETTING The Northern California Kaiser Permanente Health System (approximately 3.3 million membership population) PARTICIPANTS A total of 11,119 patients hospitalized for acute stroke from 1996 to 2003. The cohort includes patients discharged from acute care after a stroke. Postacute care rehabilitation services were evaluated according to the level of care ever-received within the 365 days after discharge from acute care, including inpatient rehabilitation hospital (IRH), skilled nursing facility (SNF), home health and outpatient, or no rehabilitation services. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Service delivery. RESULTS Patients discharged to an IRH had longer lengths of stay in acute care. Patients with hemorrhagic stroke were less likely to be treated in an IRH. Patients whose highest level of rehabilitation was SNF were older and more likely to be women. After adjusting for age and other covariates, women were less likely to go to an IRH than men. Asian and black patients were more likely than white patients to be treated in an IRH or SNF. Also more likely to go to an IRH were patients from higher socioeconomic groups, from urban areas, and from geographic areas close to the regional rehabilitation hospital. CONCLUSIONS These results suggest variation in care delivery and extent of postacute care based on differences in patient demographics and geographic factors. Results also varied over time. Some minority populations in this cohort appeared to be more likely to receive IRH care, possibly because of disease severity, family support systems, cultural factors, or differences in referral patterns.
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Affiliation(s)
- M Elizabeth Sandel
- Physical Medicine and Rehabilitation, Napa Solano Service Area, and Research and Training, Kaiser Foundation Rehabilitation Center, Vallejo, CA 94589, USA.
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19
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Ottenbacher KJ, Graham JE. The State-of-the-Science: Access to Postacute Care Rehabilitation Services. A Review. Arch Phys Med Rehabil 2007; 88:1513-21. [DOI: 10.1016/j.apmr.2007.06.761] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 06/21/2007] [Accepted: 06/22/2007] [Indexed: 11/29/2022]
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