1
|
Man S, Bruckman D, Uchino K, Schold JD, Dalton J. Racial, Ethnic, and Regional Disparities of Post-Acute Service Utilization After Stroke in the United States. Neurol Clin Pract 2024; 14:e200329. [PMID: 39036785 PMCID: PMC11259533 DOI: 10.1212/cpj.0000000000200329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 04/02/2024] [Indexed: 07/23/2024]
Abstract
Background and Objectives Post-acute care is critical for patient functional recovery and successful community transition. This study aimed to understand the current racial, ethnic, and regional disparities in post-acute service utilization after stroke. Methods This retrospective cross-sectional study included patients hospitalized for ischemic stroke and intracerebral hemorrhage in 2017-2018 using the National Inpatient Sample. Discharge destinations were classified as follows: (1) facility including inpatient rehabilitation, skilled nursing facility, and facility hospice; (2) home health care (HHC), including home health and home hospice; and (3) home without HHC. Multinomial logistic regression was used to study the odds of discharge to a facility over home and HHC over home without HHC by race, ethnicity, insurance, and census division, adjusting for clinical factors and survey design. Results Among the 1,000,980 weighted ischemic stroke admissions, 66.9% were White, 17.6% Black, 9.5% Hispanic, 3.1% Asian American/Pacific Islander, and 0.4% Native American. Relative to private insurance, uninsured patients had the lowest adjusted odds of facility over home discharge (0.44; 95% CI 0.40-0.48) and HHC discharge over home without HHC (0.79; 95% CI 0.71-0.88). Compared with White patients, only Hispanic patients with Medicare/Medicaid insurance or self-pay had lower odds of facility over home discharge (adjusted OR 0.80 and 0.75, respectively; 95% CI 0.76-0.84 and 0.63-0.93). Uninsured Hispanic patients also had lower odds of HHC discharge over home without HHC than White patients (0.74; 95% CI 0.57-0.97). Facility discharge rate was the highest in East North Central (39.2%) and lowest in Pacific (31.2%). HHC discharge rate was the highest in New England (20.2%) and lowest in West North Central (10.3%), which had the highest home without HHC discharge (46.1%). Compared with New England, other census divisions had lower odds of facility over any home discharge with Pacific being the lowest (adjusted OR, 0.66; 95% CI 0.60-0.71) and HHC over home without HHC discharge with West North Central being the lowest (adjusted OR, 0.33; 95% CI 0.29-0.38). Similar patterns were observed in intracerebral hemorrhage. Discussion Significant insurance-dependent racial and ethnic disparities and regional variations were evident in post-acute service utilization after stroke. Targeted efforts are needed to improve post-acute service access for uninsured patients especially Hispanic patients and people in certain regions.
Collapse
Affiliation(s)
- Shumei Man
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - David Bruckman
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Ken Uchino
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Jesse D Schold
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Jarrod Dalton
- Department of Neurology and Cerebrovascular Center (SM, KU), Neurological Institute, Cleveland Clinic, OH; Center for Population Health Research (DB, JDS, JD), Department of Quantitative Health Sciences, Cleveland Clinic, OH
| |
Collapse
|
2
|
Lisabeth LD, Gallo LC, Prvu-Bettger J, Kwicklis M, Almendarez EM, Morgenstern LB. Outcomes Among Mexican American and Non-Hispanic White Informal Stroke Caregivers. Stroke 2024; 55:2003-2010. [PMID: 38966984 PMCID: PMC11262960 DOI: 10.1161/strokeaha.124.047035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/10/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Informal home care is prevalent among Mexican American stroke survivors, but data on the impact on caregivers are not available. The aim was to assess ethnic differences in informal stroke caregiving and caregiver outcomes at 90 days poststroke. METHODS Informal caregivers were recruited from the population-based Brain Attack Surveillance in Corpus Christi Project (2019-2023), conducted in a bi-ethnic community in Texas. Caregivers of community-dwelling stroke survivors who were not cognitively impaired and not employed by a formal caregiving agency were interviewed. Interviews included sociodemographics, dyad characteristics, Modified Caregiver Strain Index (range 0-26, higher more positive), Positive Aspects of Caregiving scale (range, 5-45, higher more), Patient Health Questionnaire-8 (range, 0-30, higher worse), and PROMIS (Patient-Reported Outcomes Measurement Information System)-10 physical (range, 16.2-67.7, higher better) and mental health (range, 21.2-67.6, higher better) summary scores. Stroke survivor data was from interviews and medical records. Propensity score methods were used to balance caregiver and patient factors among Mexican American and Non-Hispanic White caregivers by fitting a model with ethnicity of caregiver as the outcome and predictors being caregiver sociodemographics, patient-caregiver dyad characteristics, and patient sociodemographics and functional disability. Propensity scores were included as a covariate in regression models, considering the association between ethnicity and outcomes. RESULTS Mexican American caregivers were younger, more likely female, and more likely a child of the stroke survivor than Non-Hispanic White caregivers. Mexican American caregiver ethnicity was associated with less caregiver strain (β, -1.87 [95% CI, -3.51 to -0.22]) and depressive symptoms (β, -2.02 [95% CI, -3.41 to -0.64]) and more favorable mental health (β, 4.90 [95% CI, 2.49-7.31]) and positive aspects of caregiving (β, 3.29 [95% CI, 1.35-5.23]) but not associated with physical health. CONCLUSIONS Understanding the mechanisms behind more favorable caregiver outcomes in Mexican American people may aid in the design of culturally sensitive interventions to improve both caregiver and stroke survivor outcomes, potentially across all race and ethnic groups.
Collapse
Affiliation(s)
- Lynda D Lisabeth
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (L.D.L., M.K., L.B.M.)
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.D.L., L.B.M.)
| | - Linda C Gallo
- Department of Psychology, College of Sciences, San Diego State University, CA (L.C.G.)
| | | | - Madeline Kwicklis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (L.D.L., M.K., L.B.M.)
| | | | - Lewis B Morgenstern
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor (L.D.L., M.K., L.B.M.)
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.D.L., L.B.M.)
| |
Collapse
|
3
|
Hassani S, Bou Dargham T, Cantrell S, Ikramuddin S, Feng W. Minorities are under-reported and females are under-represented in stroke motor recovery trials. Top Stroke Rehabil 2024:1-5. [PMID: 39074068 DOI: 10.1080/10749357.2024.2384324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 07/21/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Inclusion of diverse patient populations in stroke rehabilitation clinical trials is key for generalizability and detecting differences in subgroups. The aim of this study was to assess the reporting and inclusion of race, ethnicity, and sex in publications in post-stroke motor recovery clinical trials over the past 5 years. METHODS We conducted a systematic review of stroke motor recovery trials conducted only within the United States with at least one control group and published between 2019 and 2023. The percent of racial minorities, ethnicities, and women enrolled in the trials was extracted and calculated for those trials using available data found in the manuscript or on clinicaltrials.gov. RESULTS Sixty-eight trials (total of 2,801 participants) met the inclusion criteria and were included in the analysis. 100%, 35%, and 21% of the trials included reported enrollment by sex, race, and ethnicity in the manuscript. All publications reported sex and 38% of the subjects were female. Among the trials reporting race, 59% of the participants were White, followed by 34% Black, 0.4% Native American, 4% Asian, and 3% Other. Among the trials that reported ethnicity, Hispanic or Latino participants were represented as 13% of the total participants. CONCLUSIONS In the past 5 years, while all stroke rehab trial publications reported data on sex, they underrepresented women. Most publications did not report race or ethnicity. Improvement in reporting of race/ethnicity in stroke motor recovery trials is needed for understanding of progress with inclusion, and improvement in inclusion of women is needed for better generalizability.
Collapse
Affiliation(s)
- Sara Hassani
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Tarek Bou Dargham
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Sarah Cantrell
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Salman Ikramuddin
- Department of Neurology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
4
|
Delhey LM, Shi X, Morgenstern LB, Brown DL, Smith MA, Case EC, Springer MV, Lisabeth LD. Neighborhood Resources and Health Outcomes Among Stroke Survivors in a Population-Based Cohort. J Am Heart Assoc 2024; 13:e034308. [PMID: 38958125 PMCID: PMC11292760 DOI: 10.1161/jaha.124.034308] [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: 03/15/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Stroke survivors believe neighborhood resources such as community centers are beneficial; however, little is known about the influence of these resources on stroke outcomes. We evaluated whether residing in neighborhoods with greater resource density is associated with favorable post-stroke outcomes. METHODS AND RESULTS We included Mexican American and non-Hispanic White stroke survivors from the Brain Attack Surveillance in Corpus Christi project (2009-2019). The exposure was density of neighborhood resources (eg, community centers, restaurants, stores) within a residential census tract at stroke onset. Outcomes included time to death and recurrence, and at 3 months following stroke: disability (activities of daily living/instrumental activities of daily living), cognition (Modified Mini-Mental State Exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life scale). We fit multivariable Cox regression and mixed linear models. We considered interactions with stroke severity, ethnicity, and sex. Among 1786 stroke survivors, median age was 64 years (interquartile range, 56-73), 55% men, and 62% Mexican American. Resource density was not associated with death, recurrence, or depression. Greater resource density (75th versus 25th percentile) was associated with more favorable cognition (Modified Mini-Mental State Exam mean difference=0.838, 95% CI=0.092, 1.584) and among moderate-severe stroke survivors, with more favorable functioning (activities of daily living/instrumental activities of daily living=-0.156 [95% CI, -0.284 to 0.027]) and quality of life (abbreviated Stroke-Specific Quality of Life scale=0.194 [95% CI, 0.029-0.359]). CONCLUSIONS We observed associations between greater resource density and cognition overall and with functioning and quality of life among moderate-severe stroke survivors. Further research is needed to confirm these findings and determine if neighborhood resources may be a tool for recovery.
Collapse
Affiliation(s)
- Leanna M. Delhey
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Xu Shi
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Lewis B. Morgenstern
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
- Stroke Program, University of Michigan Medical SchoolAnn ArborMIUSA
| | - Devin L. Brown
- Stroke Program, University of Michigan Medical SchoolAnn ArborMIUSA
| | - Melinda A. Smith
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Erin C. Case
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | | | - Lynda D. Lisabeth
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMIUSA
| |
Collapse
|
5
|
Burke JF, Copeland LL, Sussman JB, Hayward RA, Gross AL, Briceño EM, Whitney R, Giordani BJ, Elkind MSV, Manly JJ, Gottesman RF, Gaskin DJ, Sidney S, Yaffe K, Sacco RL, Heckbert SR, Hughes TM, Galecki AT, Levine DA. Development and validation of the Michigan Chronic Disease Simulation Model (MICROSIM). PLoS One 2024; 19:e0300005. [PMID: 38753617 PMCID: PMC11098406 DOI: 10.1371/journal.pone.0300005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/19/2024] [Indexed: 05/18/2024] Open
Abstract
Strategies to prevent or delay Alzheimer's disease and related dementias (AD/ADRD) are urgently needed, and blood pressure (BP) management is a promising strategy. Yet the effects of different BP control strategies across the life course on AD/ADRD are unknown. Randomized trials may be infeasible due to prolonged follow-up and large sample sizes. Simulation analysis is a practical approach to estimating these effects using the best available existing data. However, existing simulation frameworks cannot estimate the effects of BP control on both dementia and cardiovascular disease. This manuscript describes the design principles, implementation details, and population-level validation of a novel population-health microsimulation framework, the MIchigan ChROnic Disease SIMulation (MICROSIM), for The Effect of Lower Blood Pressure over the Life Course on Late-life Cognition in Blacks, Hispanics, and Whites (BP-COG) study of the effect of BP levels over the life course on dementia and cardiovascular disease. MICROSIM is an agent-based Monte Carlo simulation designed using computer programming best practices. MICROSIM estimates annual vascular risk factor levels and transition probabilities in all-cause dementia, stroke, myocardial infarction, and mortality in a nationally representative sample of US adults 18+ using the National Health and Nutrition Examination Survey (NHANES). MICROSIM models changes in risk factors over time, cognition and dementia using changes from a pooled dataset of individual participant data from 6 US prospective cardiovascular cohort studies. Cardiovascular risks were estimated using a widely used risk model and BP treatment effects were derived from meta-analyses of randomized trials. MICROSIM is an extensible, open-source framework designed to estimate the population-level impact of different BP management strategies and reproduces US population-level estimates of BP and other vascular risk factors levels, their change over time, and incident all-cause dementia, stroke, myocardial infarction, and mortality.
Collapse
Affiliation(s)
- James F. Burke
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | | | - Jeremy B. Sussman
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, United States of America
- Ann Arbor Veteran’s Affairs Hospital, Center for Clinical Management and Research, Ann Arbor, MI, United States of America
| | - Rodney A. Hayward
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, United States of America
- Ann Arbor Veteran’s Affairs Hospital, Center for Clinical Management and Research, Ann Arbor, MI, United States of America
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School Public Health, Baltimore, MD, United States of America
| | - Emily M. Briceño
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Department of Physical Medicine and Rehabilitation, U-M, Ann Arbor, MI, United States of America
| | - Rachael Whitney
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
| | - Bruno J. Giordani
- Department of Psychiatry & Michigan Alzheimer’s Disease Center, U-M, Ann Arbor, MI, United States of America
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Jennifer J. Manly
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University, New York, NY, United States of America
| | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke (NINDS), Bethesda, MD, United States of America
| | - Darrell J. Gaskin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Stephen Sidney
- Kaiser Permanente Northern California Division of Research, Oakland, CA, United States of America
| | - Kristine Yaffe
- Departments of Psychiatry, Neurology and Epidemiology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Ralph L. Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States of America
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Timothy M. Hughes
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Andrzej T. Galecki
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Department of Biostatistics, U-M, Ann Arbor, MI, United States of America
| | - Deborah A. Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI, United States of America
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI, United States of America
| |
Collapse
|
6
|
Mehdipanah R, Morgenstern LB, Bettger JP, Kwicklis M, Case E, Almendarez E, Lisabeth LD. Caring for Stroke Survivors: Ethnic Differences in Informal Caregiver Needs Among Mexican American and Non-Hispanic White Communities. Stroke 2024; 55:1271-1277. [PMID: 38567501 PMCID: PMC11039376 DOI: 10.1161/strokeaha.123.043275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 02/06/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND After stroke, Mexican American (MA) individuals have worse 90-day neurological, functional, cognitive, and quality of life outcomes and a higher prevalence of poststroke depression compared with non-Hispanic White (NHW) individuals. MA individuals receive more help through informal, unpaid caregiving than NHW individuals. We examined ethnic differences in needs identified by MA and NHW stroke caregivers. METHODS Caregivers were identified from the population-based BASIC study (Brain Attack Surveillance in Corpus Christi) in Nueces County, Texas from October 2019 to November 2021. Responses to the Caregiver Needs and Concerns Checklist were collected at 90-day poststroke to assess caregiver needs. Using the cross-sectional sample, prevalence scores and bivariate analyses were used to examine ethnic differences between Caregiver Needs and Concerns Checklist items. Linear regression was used to examine adjusted associations of ethnicity with the total average needs for each domain. Models were adjusted for patient and caregiver age and sex, caregiver education level, and employment status, patient insurance status, prestroke function, cognitive status, language, and functional outcome at 90 days, intensity and duration of caregiving, presence of other caregivers (paid/unpaid), and cohabitation of patient and caregiver. RESULTS A total of 287 were approached, and 186 stroke caregivers were included with a median age of 54.2 years and 80.1% being women caregivers: 74.3% MA and 25.7% NHW individuals. MA caregivers had significantly lower education ( CONCLUSIONS MA stroke caregivers have greater information needs compared with NHW caregivers and a greater number of needs overall. This information can help improve resources to help with poststroke recovery, improve caregiver well-being, and strengthen health equity.
Collapse
Affiliation(s)
| | | | | | | | - Erin Case
- School of Public Health, University of Michigan, Ann Arbor, MI
| | | | | |
Collapse
|
7
|
Chavez AA, Simmonds KP, Venkatachalam AM, Ifejika NL. Health Care Disparities in Stroke Rehabilitation. Phys Med Rehabil Clin N Am 2024; 35:293-303. [PMID: 38514219 DOI: 10.1016/j.pmr.2023.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.
Collapse
Affiliation(s)
- Audrie A Chavez
- Brain Injury Medicine Fellow, Spaulding Rehabilitation, Harvard University, Cambridge, MA, USA
| | - Kent P Simmonds
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA; Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Stop 9055, Dallas, TX 75390-9055, USA.
| |
Collapse
|
8
|
Perez MA, Reyes-Esteves S, Mendizabal A. Racial and Ethnic Disparities in Neurological Care in the United States. Semin Neurol 2024; 44:178-192. [PMID: 38485124 DOI: 10.1055/s-0043-1778639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The burden of neurological disease is increasing globally. In the United States, this burden is disproportionally greater for Black and Latino communities who have limited access to neurological care. Health services researchers have attempted to identify racial and ethnic disparities in neurological care and possible solutions. This article reviews the most current literature on racial and ethnic disparities in commonly encountered neurological conditions, including Stroke, Alzheimer's Disease, Multiple Sclerosis, Epilepsy, Parkinson's Disease, and Migraine. Disparities exist in disease incidence, diagnosis, access to care, treatment, outcomes, and representation in epidemiologic studies and clinical trials. Many of the disparities observed in neurological care in the United States are a consequence of longstanding racist and discriminatory policies and legislation that increase risk factors for the development of neurological disease or lead to disparities in accessing quality neurological care. Therefore, additional efforts on the legislative, community health, and healthcare system levels are necessary to prevent the onset of neurological disease and achieve equity in neurological care.
Collapse
Affiliation(s)
- Michael A Perez
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Adys Mendizabal
- Department of Neurology, University of California, Los Angeles, California
| |
Collapse
|
9
|
Zahuranec DB, Ortiz C, Lank RJ, Zhang G, Shi X, Case E, Morgenstern LB. Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project. Stroke 2024; 55:678-686. [PMID: 38214155 PMCID: PMC10922558 DOI: 10.1161/strokeaha.123.043947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/20/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Patients with severe stroke often rely on surrogate decision-makers for life-sustaining treatment decisions. We investigated ethnic differences between Mexican Americans (MAs) and non-Hispanic White (NHW) individuals in surrogate reports of physician quality of communication and shared decision-making from the OASIS study (Outcomes Among Surrogate Decision Makers in Stroke) project. METHODS Patients had ischemic stroke or intracerebral hemorrhage in Nueces County, TX. Surrogates self-identified as being involved in decisions about do-not-resuscitate orders, brain surgery, ventilator, feeding tube, or hospice/comfort care. Surrogate reports of physician quality of communication (scale score, range from 0 to 10) and shared decision-making (CollaboRATE scale score, binary score 1 versus 0) were compared by ethnicity with linear or logistic regression using generalized estimating equations, adjusted for prespecified demographics, clinical factors, and confounders. RESULTS Between April 2016 and September 2020, 320 surrogates for 257 patients with stroke enrolled (MA, 158; NHW, 85; and other, 14). Overall quality of communication score was better among surrogates of MA patients than NHW individuals after adjustment for demographics, stroke severity, and patient survival though the ethnic difference was attenuated (β, 0.47 [95% CI, -0.17 to 1.12]; P=0.15) after adjustment for trust in the medical profession and frequency of personal prayer. High CollaboRATE scale scores were more common among surrogates of MA patients than NHW individuals (unadjusted odds ratio, 1.75 [95% CI, 1.04-2.95]). This association persisted after adjustment for demographic and clinical factors though there was an interaction between patient age and ethnicity (P=0.04), suggesting that this difference was primarily in older patients. CONCLUSIONS Surrogate decision-makers of MA patients generally reported better outcomes on validated measures of quality of communication and shared decision-making than NHW individuals. Further study of outcomes among diverse populations of stroke surrogate decision-makers may help to identify sources of strength and resiliency that may be broadly applicable.
Collapse
Affiliation(s)
| | - Carmen Ortiz
- Stroke Program, University of Michigan Medical School, Ann Arbor, USA
| | - Rebecca J. Lank
- University of Iowa Carver College of Medicine, Iowa City, USA
| | - Guanghao Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
| | - Lewis B. Morgenstern
- Stroke Program, University of Michigan Medical School, Ann Arbor, USA
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
| |
Collapse
|
10
|
Lank RJ, Morgenstern LB, Ortiz C, Case E, Zahuranec DB. Barriers to Surrogate Application of Patient Values in Medical Decisions in Acute Stroke: Qualitative Study in a Biethnic Community. Neurocrit Care 2024; 40:215-224. [PMID: 37131090 PMCID: PMC10620105 DOI: 10.1007/s12028-023-01724-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/27/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND The objective of this study was to identify barriers to surrogate decision-maker application of patient values on life-sustaining treatments after stroke in Mexican American (MA) and non-Hispanic White (NHW) patients. METHODS We conducted a qualitative analysis of semistructured interviews with stroke patient surrogate decision-makers completed approximately 6 months after hospitalization. RESULTS Forty-two family surrogate decision-makers participated (median age: 54.5 years; female: 83%; patients were MA [60%] and NHW [36%], and 50% were deceased at the time of the interview). We identified three primary barriers to surrogates' applications of patient values and preferences when making decisions on life-sustaining treatments: (1) a minority of surrogates had no prior discussion of what the patient would want in the event of a serious medical illness, (2) surrogates struggled to apply prior known values and preferences to the actual decisions made, and (3) surrogates felt guilt or burden, often even in the setting of some knowledge of patient values or preferences. The first two barriers were seen to a similar degree in MA and NHW participants, though guilt or burden was reported more commonly among MA (28%) than NHW (13%) participants. Maintaining patient independence (e.g., ability to live at home, avoid a nursing home, make their own decisions) was the most important priority for decision-making for both MA and NHW participants; however, MA participants were more likely to list spending time with family as an important priority (24% vs. 7%). CONCLUSIONS Stroke surrogate decision-makers may benefit from (1) continued efforts to make advance care planning more common and more relevant, (2) assistance in how to apply their knowledge of patient values to actual treatment decisions, and (3) psychosocial support to reduce emotional burden. Barriers to surrogate application of patient values were generally similar in MA and NHW participants, though the possibility of greater guilt or burden among MA surrogates warrants further investigation and confirmation.
Collapse
Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
| | - Erin Case
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | | |
Collapse
|
11
|
Chen C, Shi X, Lisabeth LD, Kwicklis M, Malvitz M, Case E, Morgenstern LB. Mexican Americans agree to participate in longitudinal clinical research more than non-Hispanic whites. BMC Public Health 2023; 23:2060. [PMID: 37864242 PMCID: PMC10589976 DOI: 10.1186/s12889-023-16998-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND The National Institutes of Health has advocated for improved minority participation in clinical research, including clinical trials and observational epidemiologic studies since 1993. An understanding of Mexican Americans (MAs) participation in clinical research is important for tailoring recruitment strategies and enrollment techniques for MAs. However, contemporary data on MA participation in observational clinical stroke studies are rare. We examined differences between Mexican Americans (MAs) and non-Hispanic whites (NHWs) participation in a population-based stroke study. METHODS We included 3,594 first ever stroke patients (57.7% MAs, 48.7% women, median [IQR] age 68 [58-79]) from the Brain Attack Surveillance in Corpus Christi Project, 2009-2020 in Texas, USA, who were approached and invited to participate in a structured baseline interview. We defined participation as completing a baseline interview by patient or proxy. We used log-binomial models adjusting for prespecified potential confounders to estimate prevalence ratios (PR) of participation comparing MAs with NHWs. We tested interactions of ethnicity with age or sex to examine potential effect modification in the ethnic differences in participation. We also included an interaction between year and ethnicity to examine ethnic-specific temporal trends in participation. RESULTS Baseline participation was 77.0% in MAs and 64.2% in NHWs (Prevalence Ratio [PR] 1.20; 95% CI, 1.14-1.25). The ethnic difference remained after multivariable adjustment (1.17; 1.12-1.23), with no evidence of significant effect modification by age or sex (Pinteraction by age = 0.68, Pinteraction by sex = 0.83). Participation increased over time for both ethnic groups (Ptrend < 0.0001), but the differences in participation between MAs and NHWs remained significantly different throughout the 11-year time period. CONCLUSION MAs were persistently more likely to participate in a population-based stroke study in a predominantly MA community despite limited outreach efforts towards MAs during study enrollment. This finding holds hope for future research studies to be inclusive of the MA population.
Collapse
Affiliation(s)
- Chen Chen
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Xu Shi
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Lynda D Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Madeline Kwicklis
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Madelyn Malvitz
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Erin Case
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Lewis B Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA.
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
12
|
Ghosh M, Hamer O, Hill JE. The Rehabilitation of Cognitive Impairment Following Stroke: A Commentary on a Systematic Review. BRITISH JOURNAL OF NEUROSCIENCE NURSING 2023; 19:S6-S10. [PMID: 38812879 PMCID: PMC7616031 DOI: 10.12968/bjnn.2023.19.sup5.s6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Stroke is regarded as one of the leading causes of death and disability worldwide. Cognitive impairment occurs in nearly 60% of stroke survivors. Despite the high prevalence and significant impact on post-stroke functioning, there remains a lack of clarity regarding effective interventions to support rehabilitation of cognitive impairment. This article critically appraises a systematic review which assessed the effectiveness of interventions to improve clinical outcomes associated with cognition for adults, post-onset of stroke. Commentary on O'Donoghue M, Leahy S, Boland P, Galvin R, McManus J, Hayes S. Rehabilitation of cognitive deficits poststroke: systematic review and meta-analysis of randomized controlled trials. Stroke. 2022;53(5):1700–1710. 10.1161/strokeaha.121.034218
Collapse
Affiliation(s)
- M Ghosh
- Lancashire Teaching Hospitals NHS Foundation Trust
| | - O Hamer
- University of Central Lancashire
| | - J E Hill
- University of Central Lancashire
| |
Collapse
|
13
|
Delhey LM, Shi X, Morgenstern LB, Brown DL, Smith MA, Case EC, Springer MV, Lisabeth LD. Association of Neighborhood Recreation Centers and Poststroke Outcomes in a Population-Based Cohort. Stroke 2023; 54:2583-2592. [PMID: 37706339 PMCID: PMC10530069 DOI: 10.1161/strokeaha.122.041852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 08/14/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Higher neighborhood socioeconomic status has been favorably associated with stroke outcomes. This may be due to these areas having more beneficial resources such as recreational centers. We aimed to determine if neighborhood density of recreation centers is favorably associated with stroke outcomes. METHODS We conducted analyses of data from the Brain Attack Surveillance in Corpus Christi project, a cohort of stroke survivors ≥45 years of age residing in Nueces County, TX (2009-2020). We included non-Hispanic White and Mexican American incident stroke survivors, who were not institutionalized prestroke and completed baseline and follow-up assessments (N=1392). We calculated the density of fitness and recreational sports centers within their residential census tract during the year of their stroke. Outcomes included function (self-ratings on activities of daily living and instrumental activities of daily living), cognition (modified mini-mental state exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life Scale). We fit confounder-adjusted gamma-distributed mixed generalized linear models with a log link for each outcome and considered interaction with stroke severity. RESULTS On average, participants were 65 years old, 53% male, and 63% Mexican American. Median recreational centers were 1.60 per square mile (interquartile range, 0.41-3.06). Among moderate-severe stroke survivors, greater density of recreation centers (75th versus 25th percentile) was associated with more favorable function and possibly quality of life (activities of daily living/instrumental activities of daily living, 4.8% change [95% CI, -0.11% to -9.27%]; Stroke-Specific Quality of Life Scale, 3.7% change [95% CI, -0.7% to 8.2%]). Minimal nonsignificant differences were observed among the overall stroke population and those with mild stroke. CONCLUSIONS The availability of recreation centers may be beneficial for poststroke function and quality of life among those with moderate-severe stroke. If further research confirms recreation centers to be beneficial, this could inform rehabilitation following stroke.
Collapse
Affiliation(s)
- Leanna M Delhey
- Department of Epidemiology (L.M.D., L.B.M., M.A.S., E.C.C., L.D.L.), University of Michigan School of Public Health, Ann Arbor
| | - Xu Shi
- Department of Biostatistics (X.S.), University of Michigan School of Public Health, Ann Arbor
| | - Lewis B Morgenstern
- Department of Epidemiology (L.M.D., L.B.M., M.A.S., E.C.C., L.D.L.), University of Michigan School of Public Health, Ann Arbor
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.B.M., D.L.B., M.V.S.)
| | - Devin L Brown
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.B.M., D.L.B., M.V.S.)
| | - Melinda A Smith
- Department of Epidemiology (L.M.D., L.B.M., M.A.S., E.C.C., L.D.L.), University of Michigan School of Public Health, Ann Arbor
| | - Erin C Case
- Department of Epidemiology (L.M.D., L.B.M., M.A.S., E.C.C., L.D.L.), University of Michigan School of Public Health, Ann Arbor
| | - Mellanie V Springer
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.B.M., D.L.B., M.V.S.)
| | - Lynda D Lisabeth
- Department of Epidemiology (L.M.D., L.B.M., M.A.S., E.C.C., L.D.L.), University of Michigan School of Public Health, Ann Arbor
| |
Collapse
|
14
|
Vargas A, Zhang G, Shi X, Lisabeth LD, Morgenstern LB. Stroke Outcomes Among English- and Spanish-Speaking Mexican American Patients. Neurology 2023; 101:407-411. [PMID: 37045598 PMCID: PMC10501086 DOI: 10.1212/wnl.0000000000207275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVES We examined whether language preference was associated with 90-day poststroke outcomes among Mexican American (MA) patients. METHODS Patients with ischemic stroke and intracerebral hemorrhage from the population-based Brain Attack Surveillance in Corpus Christi project (2009-2018) were compared by language preference in 90-day neurologic, functional, and cognitive outcomes using weighted Tobit regression. Models were adjusted for demographics, initial NIH Stroke Scale (NIHSS), medical history, stroke characteristics, and insurance status. RESULTS Of 1,096 stroke patients, 926 were English-speaking and 170 were Spanish-only-speaking. Spanish speakers were older (p < 0.01), received less education (p < 0.01), had higher initial NIHSS values (p = 0.02), had higher prevalence of atrial fibrillation (p < 0.01), and had lower prevalence of smoking (p = 0.01) than English speakers. In fully adjusted models, Spanish-only speakers had worse neurologic outcome (NIHSS, range 0-44 [higher worse], mean difference: 1.93, p < 0.01) but no difference in functional outcome measured by activities of daily living/instrumental activities of daily living or cognitive outcome compared with English speakers. DISCUSSION This population-based study found worse neurologic but similar functional and cognitive stroke outcomes among Spanish-only-speaking MA patients compared with English-speaking MA patients.
Collapse
Affiliation(s)
- Alejandro Vargas
- From the Department of Neurological Sciences (A.V.), Rush University Medical Center, Chicago, IL; and Department of Biostatistics (G.Z., X.S.), and Stroke Program (L.D.L., L.B.M.), Michigan Medicine and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Guanghao Zhang
- From the Department of Neurological Sciences (A.V.), Rush University Medical Center, Chicago, IL; and Department of Biostatistics (G.Z., X.S.), and Stroke Program (L.D.L., L.B.M.), Michigan Medicine and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Xu Shi
- From the Department of Neurological Sciences (A.V.), Rush University Medical Center, Chicago, IL; and Department of Biostatistics (G.Z., X.S.), and Stroke Program (L.D.L., L.B.M.), Michigan Medicine and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Lynda D Lisabeth
- From the Department of Neurological Sciences (A.V.), Rush University Medical Center, Chicago, IL; and Department of Biostatistics (G.Z., X.S.), and Stroke Program (L.D.L., L.B.M.), Michigan Medicine and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Lewis B Morgenstern
- From the Department of Neurological Sciences (A.V.), Rush University Medical Center, Chicago, IL; and Department of Biostatistics (G.Z., X.S.), and Stroke Program (L.D.L., L.B.M.), Michigan Medicine and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor.
| |
Collapse
|
15
|
Briceño EM, Dong L, Levine DA, Kwicklis M, Lisabeth LD, Morgenstern LB. Cognitive recovery trajectories 3 months following stroke in Mexican American and non-Hispanic white adults. J Stroke Cerebrovasc Dis 2023; 32:106902. [PMID: 36459957 PMCID: PMC10249629 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/01/2022] [Accepted: 11/19/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES We examined whether cognitive trajectories from 0-3 months after stroke differ between Mexican Americans (MAs) and non-Hispanic white (NHW) adults. MATERIALS AND METHODS The sample included 701 participants with ischemic stroke (62% MA; 38% NHW) from the population-based stroke surveillance study, the Brain Attack Surveillance in Corpus Christi (BASIC) Project, between 2008-2013. The outcome was the modified Mini Mental State Examination (3MSE, range 0-100 lower scores worse). Linear mixed effects models were utilized to examine the association between ethnicity and cognitive trajectories from 0-3 months following stroke, adjusting for confounders. RESULTS MAs were younger, had lower educational attainment, and fewer had health insurance than NHWs (all p< 0.01). A smaller proportion of MAs were rated by informants as exhibiting pre-stroke cognitive decline than NHW (p < .0.05). After accounting for confounders, MAs demonstrated lower cognitive performance at post-stroke baseline and at 3-months following stroke (-2.00; 95% CI =-3.92, -0.07). Cognitive trajectories from 0-3 months following stroke were indicative of modest cognitive recovery (increase of 0.034/day, 95% CI =0.030-0.036) and did not differ between MAs and NHWs (p = 0.68). CONCLUSION We found no evidence that cognitive trajectories in the first three months following stroke differed between MAs and NHWs. MAs demonstrated lower cognitive performance shortly after stroke and at three months following stroke compared to NHWs. Further research is needed to identify factors contributing to ethnic disparities in cognitive outcomes after stroke.
Collapse
Affiliation(s)
- Emily M Briceño
- Department of Physical Medicine & Rehabilitation, University of Michigan Medical School, 325 E. Eisenhower Blvd, Ann Arbor, MI 48108, United States.
| | - Liming Dong
- Department of Epidemiology, University of Michigan School of Public Health and Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, 325 E. Eisenhower Blvd, Ann Arbor, MI 48108, United States
| | - Deborah A Levine
- Departments of Internal Medicine and Neurology and Cognitive Health Services Research Program, University of Michigan Medical School, 325 E. Eisenhower Blvd, Ann Arbor, MI 48108, United States
| | - Madeline Kwicklis
- Department of Epidemiology, University of Michigan School of Public Health, 325 E. Eisenhower Blvd, Ann Arbor, MI 48108, United States
| | - Lynda D Lisabeth
- Department of Epidemiology and Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Department of Neurology and Stroke Program, University of Michigan Medical School, 325 E. Eisenhower Blvd, Ann Arbor, MI 48108, United States
| | - Lewis B Morgenstern
- Department of Neurology and Stroke Program, University of Michigan Medical School; Department of Epidemiology and Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, 325 E. Eisenhower Blvd, Ann Arbor, MI 48108, United States
| |
Collapse
|
16
|
Lisabeth LD, Brown DL, Dong L, Zahuranec DB, Kwicklis M, Shi X, Case E, Smith MA, Campbell M, Carrera JF, Morgenstern LB. Outcomes in the Year After First-Ever Ischemic Stroke in a Bi-Ethnic Population. Ann Neurol 2023; 93:348-356. [PMID: 36134521 PMCID: PMC9892337 DOI: 10.1002/ana.26513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate stroke outcomes at 3, 6, and 12 months post-stroke overall and by ethnicity in a population-based, longitudinal study. METHODS First-ever ischemic strokes (2014-2019, n = 1,332) among Mexican American persons (n = 807) and non-Hispanic white persons (n = 525) were identified from the Brain Attack Surveillance in Corpus Christi Project. Data were collected from patient or proxy interviews (baseline, 3, 6, and 12 months post-stroke) and medical records, including functional (activities of daily living/instrumental activities of daily living score), neurological (National Institutes of Health Stroke Scale), cognitive (Modified Mini-Mental State Examination), and quality of life (QOL) outcomes (12-domain Stroke-specific Quality of Life scale). Outcome trajectories were analyzed using multivariable adjusted linear models, with generalized estimating equations to account for within-subject correlations; interactions between ethnicity and time were included to investigate ethnic differences in outcomes. RESULTS The median age was 67 years (interquartile range 58,78), 48.5% were women, and 60.6% were Mexican American persons. For all outcomes, significant improvement was seen between 3 and 6 months (p < 0.05 for all), with stability between 6 and 12 months. Mexican American persons had significantly worse outcomes compared with non-Hispanic white persons at all time points (3, 6, and 12 months), with the exception of the National Institutes of Health Stroke Scale, which did not differ by ethnicity at 6 and 12 months, and the average change in outcomes did not vary significantly by ethnicity. INTERPRETATION Outcomes were at their worst at 3 months post-stroke, and ethnic disparities were already present, suggesting the need for early assessment and strategies to improve outcomes and possibly reduce disparities. ANN NEUROL 2023;93:348-356.
Collapse
Affiliation(s)
- Lynda D Lisabeth
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan,Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Devin L Brown
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Liming Dong
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Darin B Zahuranec
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Madeline Kwicklis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Melinda A Smith
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Morgan Campbell
- CHRISTUS Spohn Hospitals, CHRISTUS Health system, Corpus Christi, Texas
| | - Joseph F Carrera
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lewis B Morgenstern
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan,Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan,Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
17
|
Morgenstern LB, Almendarez EM, Mehdipanah R, Kwicklis M, Case E, Smith MA, Lisabeth LD. Methods and early recruitment of the Brain Attack Surveillance in Corpus Christi-Post-acute Care (BASIC-PAC) Project. J Stroke Cerebrovasc Dis 2022; 31:106851. [PMID: 36335753 PMCID: PMC10024336 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) have worse stroke outcomes. We report here the methods, background literature, and initial recruitment of the Brain Attack Surveillance in Corpus Christi-Post Acute Care (BASIC-PAC) Project which aims to explore PAC in MAs and NHWs from multiple perspectives: patients, caregivers, and community. MATERIALS AND METHODS Rigorous active and passive stroke surveillance captures all strokes in Nueces County, Texas. Stroke patients are followed for 90 days to determine their care transitions and factors influencing their rehabilitation setting. Informal caregivers of the stroke patients are identified and interviewed at 90 days to determine aspects of their caregiving and caregiver outcomes. Available community resources are compared with stated needs among stroke patient and caregivers to determine unmet needs. RESULTS Between October, 2019 and October, 2021, among the 629 stroke patients eligible, 413 were MA, 227 were NHW. Of the 629, all of the six follow-up calls were completed by 355 of the MAs (87%) and 191 of the NHWs (87%). During this same time period, we attempted to approach 621 potential caregivers. Of these, 458 (73.8%) potential caregivers participated in interviews to determine caregiver eligibility, and 373 (81.4%) of these participating potential caregivers met the eligibility criteria. CONCLUSIONS BASIC-PAC has strong initial recruitment and is poised to provide valuable data on multiple aspects of PAC and how PAC differs by ethnicity and contributes to worse stroke outcomes in MAs. Based on the study findings, interventions can be developed that will improve stroke health equity.
Collapse
Affiliation(s)
- Lewis B Morgenstern
- Stroke Program, University of Michigan Medical School, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, United States.
| | - Elizabeth M Almendarez
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Roshanak Mehdipanah
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, United States
| | - Madeline Kwicklis
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Melinda A Smith
- Department of Epidemiology, University of Michigan School of Public Health, United States
| | - Lynda D Lisabeth
- Stroke Program, University of Michigan Medical School, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, United States
| |
Collapse
|
18
|
Horvat M, Lisabeth LD, Lim J, He K, Dasgupta R, Case E, Chervin RD, Brown DL. Ethnic differences exist in sleepiness 3 Months after ischemic stroke. Sleep Med 2022; 100:219-224. [PMID: 36115141 PMCID: PMC9669219 DOI: 10.1016/j.sleep.2022.08.017] [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: 10/16/2021] [Revised: 07/13/2022] [Accepted: 08/25/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE/BACKGROUND To examine the association between ethnicity and 90-day post-stroke subjective sleepiness, an important determinant of quality of life, as measured by the Epworth Sleepiness Scale (ESS), among ischemic stroke survivors. PATIENTS/METHODS Mexican American (MA) and non-Hispanic white (NHW) recent ischemic stroke patients were identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2016). Subjects completed a baseline interview and 90-day outcome assessment that included the ESS. Excessive daytime sleepiness was defined as an ESS >10. Tobit regression models were used to assess associations between ethnicity and ESS unadjusted and adjusted for multiple potential confounders. RESULTS Among 1,181 (62.5% MA) subjects, mean ESS at 90 days was 8.9 (SD 6.0) among MA and 7.4 (SD 4.9) among NHW subjects: 1.45 (95% CI: 0.75, 2.15) points higher among MA than NHW subjects. After adjustment, mean ESS at 90 days was 1.16 (95% CI: 0.38, 1.94) points higher among MAs than NHWs. The prevalence of excessive daytime sleepiness was 39% among MA and 30% among NHW subjects (p = 0.0013). CONCLUSIONS Ninety days after stroke, sleepiness is worse in MAs compared to NHWs, even after accounting for potential confounding variables. Further studies should address ways to reduce this disparity.
Collapse
Affiliation(s)
- Marri Horvat
- Sleep Disorders Center, Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lynda D Lisabeth
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA; Stroke Program - Cardiovascular Center, Department of Neurology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jaewon Lim
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, USA
| | - Kevin He
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, USA
| | - Rahul Dasgupta
- Sleep Disorders Center, Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Erin Case
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA; Stroke Program - Cardiovascular Center, Department of Neurology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Ronald D Chervin
- Sleep Disorders Center, Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Devin L Brown
- Stroke Program - Cardiovascular Center, Department of Neurology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
19
|
Hirsch JA, Michael YL, Moore KA, Melly S, Hughes TM, Hayden K, Luchsinger JA, Jimenez MP, James P, Besser LM, Sánchez B, Diez Roux AV. Longitudinal neighbourhood determinants with cognitive health and dementia disparities: protocol of the Multi-Ethnic Study of Atherosclerosis Neighborhoods and Aging prospective cohort study. BMJ Open 2022; 12:e066971. [PMID: 36368762 PMCID: PMC9660618 DOI: 10.1136/bmjopen-2022-066971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The burden of Alzheimer's disease (AD) and AD-related dementias (ADRD) is increasing nationally and globally, with disproportionate impacts on lower-income, lower education and systematically marginalised older adults. Presence of inequalities in neighbourhood factors (eg, social context, physical and built environments) may affect risk of cognitive decline and be key for intervening on AD/ADRD disparities at the population level. However, existing studies are limited by a dearth of longitudinal, detailed neighbourhood measures linked to rich, prospective cohort data. Our main objective is to identify patterns of neighbourhood change related to prevalence of-and disparities in-cognitive decline and dementia. METHODS AND ANALYSES We describe the process of collecting, processing and linking extensive neighbourhood data to the Multi-Ethnic Study of Atherosclerosis (MESA), creating a 25+ years dataset. Within the MESA parent study, the MESA Neighborhoods and Aging cohort study will characterise dynamic, longitudinal neighbourhood social and built environment variables relevant to cognition for residential addresses of MESA participants. This includes administering new surveys, expanding residential address histories, calculating new measures derived from spatial data and implementing novel deep learning algorithms on street-level imagery. Applying novel statistical techniques, we will examine associations of neighbourhood environmental characteristics with cognition and clinically relevant AD/ADRD outcomes. We will investigate determinants of disparities in outcomes by socioeconomic position and race/ethnicity and assess the contribution of neighbourhood environments to these disparities. This project will provide new evidence about pathways between neighbourhood environments and cognitive outcomes, with implications for policies to support healthy ageing. ETHICS AND DISSEMINATION This project was approved by the University of Washington and Drexel University Institutional Review Boards (protocols #00009029 and #00014523, and #180900605). Data will be distributed through the MESA Coordinating Center. Findings will be disseminated in peer-reviewed scientific journals, briefs, presentations and on the participant website.
Collapse
Affiliation(s)
- Jana A Hirsch
- Urban Health Collaborative and Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Yvonne L Michael
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Kari A Moore
- Urban Health Collaborative, Drexel University, Philadelphia, Pennsylvania, USA
| | - Steven Melly
- Urban Health Collaborative, Drexel University, Philadelphia, Pennsylvania, USA
| | - Timothy M Hughes
- Department of Internal Medicine, Medical Center Boulevard, Winston-Salem, Carolina, USA
| | - Kathleen Hayden
- Department of Social Sciences and Health Policy, Bowman Gray Center for Medical Education, Winston-Salem, Carolina, USA
| | - Jose A Luchsinger
- Department of Medicine, Columbia University, New York, New York, USA
| | - Marcia P Jimenez
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Peter James
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Population Medicine, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Lilah M Besser
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Brisa Sánchez
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Ana V Diez Roux
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
20
|
Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2538] [Impact Index Per Article: 1269.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
21
|
Jiang X, Morgenstern LB, Cigolle CT, Wang L, Claflin ES, Lisabeth LD. Multiple Chronic Conditions Explain Ethnic Differences in Functional Outcome Among Patients With Ischemic Stroke. Stroke 2022; 53:120-127. [PMID: 34517767 PMCID: PMC8712371 DOI: 10.1161/strokeaha.120.032595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Mexican Americans (MAs) have worse stroke outcomes and a different profile of multiple chronic conditions (MCC) compared with non-Hispanic White people. MCC has implications for stroke treatment, complications, and poststroke care, which impact poststroke functional outcome (FO). We sought to assess the contribution of MCC to the ethnic difference in FO at 90 days between MAs and non-Hispanic White people. METHODS In a prospective cohort of ischemic stroke patients (2008-2016) from Nueces County, Texas, data were collected from patient interviews, medical records, and hospital discharge data. MCC was assessed using a stroke-specific and function-relevant index (range, 0-35; higher scores greater MCC burden). Poststroke FO was measured by an average score of 22 activities of daily living (ADLs) and instrumental ADLs at 90 days (range, 1-4; higher scores worse FO). The contribution of MCC to the ethnic difference in FO was assessed using Tobit regression. Effect modification by ethnicity was examined. RESULTS Among the 896 patients, 70% were MA and 51% were women. Mean age was 68±12.2 years; 33% of patients were dependent in ADL/instrumental ADLs (FO score >3, representing a lot of difficulty with ADL/instrumental ADLs) at 90 days. MAs had significantly higher age-adjusted MCC burden compared with non-Hispanic White people. Patients with high MCC score (at the 75th percentile) on average scored 0.70 points higher in the FO score (indicating worse FO) compared with those with low MCC score (at the 25th percentile) after adjusting for age, initial National Institutes of Health Stroke Scale, and sociodemographic factors. MCC explained 19% of the ethnic difference in FO, while effect modification by ethnicity was not statistically significant. CONCLUSIONS MAs had a higher age-adjusted MCC burden, which partially explained the ethnic difference in FO. The prevention and treatment of MCC could potentially mitigate poststroke functional impairment and lessen ethnic disparities in stroke outcomes.
Collapse
Affiliation(s)
- Xiaqing Jiang
- Department of Epidemiology, School of Public Health, University of Michigan
| | - Lewis B. Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, Stroke Program, University of Michigan Medical School
| | - Christine T. Cigolle
- Department of Family Medicine and Internal Medicine, University of Michigan Medical School, Geriatric Research, Education and Clinical Center, VA Ann Arbor Healthcare System
| | - Lu Wang
- Department of Biostatistics, School of Public Health, University of Michigan
| | - Edward S. Claflin
- Stroke Program, University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School
| | - Lynda D. Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Stroke Program, University of Michigan Medical School
| |
Collapse
|
22
|
Jones E, Kumar A, Lopez-Rivera V, Sebaugh J, Kamal H, Sheth SA, Sharrief A, Zha A. Racial and Ethnic Disparities in Functional Outcome after Thrombectomy: A Cohort Study of an Integrated Stroke Network. J Stroke Cerebrovasc Dis 2021; 30:106131. [PMID: 34655973 PMCID: PMC8578430 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/11/2021] [Accepted: 09/17/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Previous studies have shown racial disparities in access to treatment and outcomes in ischemic stroke patients. We sought to define racial disparities in functional outcomes among ischemic stroke patients receiving endovascular thrombectomy (EVT). MATERIALS AND METHODS We performed a retrospective review of patients in our institution's prospectively collected stroke patient registry from 08/2015 to 06/2019 at 1 comprehensive and 2 thrombectomy-ready stroke centers. We reviewed patients aged ≥ 18 who received mechanical thrombectomy including only patients with race/ethnicity data belonging to the 3 largest race/ethnic groups: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (HIS). We compared baseline characteristics and performed multivariable logistic regression to evaluate differences in good functional outcome defined as 90-day modified Rankin score (90 day mRS 0-2) as the primary outcome. Secondary outcomes were discharge disposition, length of stay, and excellent functional outcome (90 day mRS 0-1). Results are given as OR [95% CI]. RESULTS Among 666 patients that met inclusion criteria, 45% were NHW, 30% were NHB, and 19% were HIS. NHB and HIS patients were younger than NHW (average age NHB 62; HIS 64; and NHW 70; p < 0.001). Diabetes was more prevalent in NHB (32%, p = 0.02) and HIS (47%, p < 0.001) compared to NHW (23%). There were no significant racial differences in pre-morbid mRS, arrival NIHSS, tPA treatment rates. There was no difference in primary outcome by race comparing NHW to the other racial groups (OR 1.08 [0.68-1.72]) but compared to HIS patients, NHW had a higher likelihood of the secondary outcome of excellent functional outcome (aOR 2.23 [1.01-4.93]) defined as mRS 0-1. CONCLUSIONS In this study of over 600 patients treated with EVT, we did not find significant racial disparities in functional outcome except for less excellent functional outcome in HIS compared to NHW. Further study on disparities in post-acute stroke care is needed.
Collapse
Affiliation(s)
- Erica Jones
- Department of Neurology, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, United States.
| | - Aditya Kumar
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Victor Lopez-Rivera
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Jacob Sebaugh
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Haris Kamal
- Department of Neurosurgery, New York Medical College Westchester Medical Center, White Plains, NY 10605, United States
| | - Sunil A Sheth
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Anjail Sharrief
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States; Department of Neurology, Institute of Stroke and Cerebrovascular Disease, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Alicia Zha
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States; Department of Neurology, Institute of Stroke and Cerebrovascular Disease, University of Texas McGovern Medical School, Houston, TX 77030, United States
| |
Collapse
|
23
|
Morgenstern LB, Hollenhorst CN, Gallo LC, Hsu CW, Kim S, Gibbs R, Case E, Lisabeth LD. Ethnic Differences in Informal Caregiving After Stroke. Stroke 2021; 52:3938-3943. [PMID: 34455820 DOI: 10.1161/strokeaha.120.032740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Informal (unpaid) caregiving usually provided by family is important poststroke. We studied whether the prevalence of informal caregiving after stroke differs between Mexican Americans (MAs) and non-Hispanic Whites (NHWs). METHODS Between October 2014 and December 2018, participants in the BASIC (Brain Attack Surveillance in Corpus Christi) project in Nueces County, Texas, were interviewed 90 days after stroke to determine which activities of daily living they required help with and whether family provided informal caregiving. Ethnic differences between MAs and NHWs were determined by logistic regression. The logistic models were stratified by formal (paid) care status. Odds ratios (95% CIs) are reported with NHW as the referent group. Fisher exact tests were used to assess the association of ethnicity with relationship of caregiver and with individual activities of daily living. RESULTS Eight hundred thirty-one patients answered the caregiving questions. Of these, 242 (29%) received family caregiving (33% of MAs and 23% of NHWs), and 142 (17%) received paid caregiving (21% of MAs and 10% of NHWs). There were no ethnic differences in stroke severity. In logistic regression analyses, among those without formal, paid care, MAs were more likely to have informal caregiving (odds ratio, 1.75 [95% CI, 1.12-2.73]) adjusted for age, National Institutes of Health Stroke Scale, prestroke modified Rankin Scale, and insurance. No ethnic differences in informal care were found among those who had formal care. There were no differences between ethnic groups in which family members provided the informal care. MAs were more likely to require help compared with NHWs for walking (P<0.0001), bathing (P<0.0001), hygiene (P=0.0012), eating (P=0.0004), dressing (P<0.0001), ambulating (P=0.0304), and toileting (P=0.0003). CONCLUSIONS MAs required more help poststroke than NHWs for assistance with activities of daily living. MAs received more help for activities of daily living through informal, unpaid caregiving than NHWs if they were not also receiving formal, paid care. Efforts to help minority and low-resource populations provide stroke care are needed.
Collapse
Affiliation(s)
- Lewis B Morgenstern
- University of Michigan Medical School, Ann Arbor (L.B.M., C.N.H., L.D.L.).,University of Michigan School of Public Health, Ann Arbor (L.B.M., C.-W.H., R.G., E.C., L.D.L.)
| | | | | | - Chia-Wei Hsu
- University of Michigan School of Public Health, Ann Arbor (L.B.M., C.-W.H., R.G., E.C., L.D.L.)
| | - Sehee Kim
- Asian Medical Center, Seoul, South Korea (S.K.)
| | - River Gibbs
- University of Michigan School of Public Health, Ann Arbor (L.B.M., C.-W.H., R.G., E.C., L.D.L.)
| | - Erin Case
- University of Michigan School of Public Health, Ann Arbor (L.B.M., C.-W.H., R.G., E.C., L.D.L.)
| | - Lynda D Lisabeth
- University of Michigan Medical School, Ann Arbor (L.B.M., C.N.H., L.D.L.).,University of Michigan School of Public Health, Ann Arbor (L.B.M., C.-W.H., R.G., E.C., L.D.L.)
| |
Collapse
|
24
|
Dong L, Williams LS, Brown DL, Case E, Morgenstern LB, Lisabeth LD. Prevalence and Course of Depression During the First Year After Mild to Moderate Stroke. J Am Heart Assoc 2021; 10:e020494. [PMID: 34184539 PMCID: PMC8403325 DOI: 10.1161/jaha.120.020494] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/19/2021] [Indexed: 01/18/2023]
Abstract
Background This study examined the prevalence and longitudinal course of depression during the first year after mild to moderate stroke. Methods and Results We identified patients with mild to moderate ischemic stroke or intracerebral hemorrhage (National Institutes of Health Stroke Scale score <16) and at least 1 depression assessment at 3, 6, or 12 months after stroke (n=648, 542, and 533, respectively) from the Brain Attack Surveillance in Corpus Christi project (2014-2016). Latent transition analysis was used to examine temporal profiles of depressive symptoms assessed by the 8-item Patient Health Questionnaire between 3 and 12 months after stroke. Mean age was 65.6 years, 49.4% were women, and 56.7% were Mexican Americans. The prevalence of depression after stroke was 35.3% at 3 months, decreased to 24.9% at 6 months, and remained stable at 25.7% at 12 months. Approximately half of the participants classified as having depression at 3 or 6 months showed clinical improvement at the next assessment. Subgroups with distinct patterns of depressive symptoms were identified, including mild/no symptoms, predominant sleep disturbance and fatigue symptoms, affective symptoms, and severe/all symptoms. A majority of participants with mild/no symptoms retained this symptom pattern over time. The probability of transitioning to mild/no symptoms was higher before 6 months compared with the later period, and severe symptoms were more likely to persist after 6 months compared with the earlier period. Conclusions The observed dynamics of depressive symptoms suggest that depression after stroke tends to persist after 6 months among patients with mild to moderate stroke and should be continually monitored and appropriately managed.
Collapse
Affiliation(s)
- Liming Dong
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMI
| | - Linda S. Williams
- Health Services Research and Development Center for Health Information and CommunicationRoudebush VA Medical CenterIndianapolisIN
- Department of NeurologyIndiana University School of MedicineIndianapolisIN
- Regenstrief Institute, Inc.IndianapolisIN
| | - Devin L. Brown
- Stroke ProgramUniversity of Michigan Medical SchoolAnn ArborMI
| | - Erin Case
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMI
| | - Lewis B. Morgenstern
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMI
- Stroke ProgramUniversity of Michigan Medical SchoolAnn ArborMI
| | - Lynda D. Lisabeth
- Department of EpidemiologyUniversity of Michigan School of Public HealthAnn ArborMI
| |
Collapse
|
25
|
Raised high-sensitivity C-reactive protein and cognitive impairment among African stroke survivors within the first three months following stroke. J Clin Neurosci 2021; 88:191-196. [PMID: 33992183 DOI: 10.1016/j.jocn.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 11/22/2022]
Abstract
Stroke remains a major factor causing death and disabilities such as cognitive impairment. There is conflicting evidence on the role and dynamics of high sensitivity C-reactive protein (hsCRP), an acute phase pro-inflammatory protein, in post-stroke cognitive impairment. This study evaluated cognitive impairment and examined its relationship with serum hsCRP in the first three months following stroke. Cognition was assessed using Montreal Cognitive Assessment test, while serum hsCRP concentrations were assessed using enzyme link immunosorbent assay kit. Data were processed using SPSS Statistics version 20.0. Sixty subjects, comprising of 30 stroke patients and 30 healthy subjects, matched for age, sex and level of education were studied. Cognitive impairment was observed among the stroke patients, while the healthy subjects showed normal cognitive function; and the difference in the cognitive scores of the two groups was highly significant (P = 0.001). There was higher prevalence of cognitive impairment among the stroke survivors compared to the non-stroke subjects. Serum hsCRP was significantly higher among the stroke survivors compared to the healthy subjects (P = 0.001). The high hsCRP level correlates well with duration of stroke and working memory domain of cognition. The data revealed a high prevalence of cognitive impairment and concurrent high serum hsCRP levels among stroke survivors in the first three months following stroke, in contrast with normal subjects. The high hsCRP level correlates with duration of stroke and working memory domain of cognition. The data suggest a role for serum hsCRP and inflammation in the development of post-stroke cognitive impairment.
Collapse
|
26
|
Stulberg EL, Twardzik E, Kim S, Hsu CW, Xu Y, Clarke P, Morgenstern LB, Lisabeth LD. Association of Neighborhood Socioeconomic Status With Outcomes in Patients Surviving Stroke. Neurology 2021; 96:e2599-e2610. [PMID: 33910941 DOI: 10.1212/wnl.0000000000011988] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine associations between neighborhood socioeconomic status (nSES) and 90-day poststroke outcomes. METHODS The Brain Attack Surveillance in Corpus Christi Project is a population-based surveillance study in Nueces County, Texas. Patients with strokes were identified between 2010 and 2016 via active and passive surveillance and enrolled in the study. nSES index is a standardized composite of 2010 Census tract-level income, wealth, education, and employment (median -4.56, interquartile range -7.48 to -0.46). The 90-day outcomes were ascertained via interview: functional status measured by the average of 22 activities of daily living/instrumental activities of daily living (range 1-4), biopsychosocial health by the Stroke-Specific Quality of Life scale (range 0-5), and depressive symptoms by the 8-item Patient Health Questionnaire (range 0-24). Associations between nSES and outcomes were estimated using confounder-adjusted generalized estimating equations with an nSES × NIH Stroke Scale score interaction term. RESULTS Seven hundred seventy-six survivors made up the analytical sample (52.96% male, 62.24% Mexican American, 52.96% ≥64 years old). Higher compared to lower nSES (mean difference comparing 75th to 25th percentile of nSES) was associated with better function (-0.27, 95% confidence interval [CI] -0.49 to -0.05), better biopsychosocial health (0.26, 95% CI 0.06-0.47), and fewer depressive symptoms (-1.77, 95% CI -3.306 to -0.48) among those with moderate to severe strokes. Among those with minor strokes, higher nSES was associated with better function (-0.13, 95% CI -0.24 to -0.02). CONCLUSIONS nSES may influence poststroke recovery. Studies should identify neighborhood characteristics that contribute to poststroke outcomes, particularly in moderate to severe stroke survivors.
Collapse
Affiliation(s)
- Eric L Stulberg
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Erica Twardzik
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Sehee Kim
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Chia-Wei Hsu
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Yuliang Xu
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Philippa Clarke
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Lewis B Morgenstern
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor
| | - Lynda D Lisabeth
- From the Department of Neurology (E.L.S.), University of Utah School of Medicine, Salt Lake City; and Departments of Epidemiology (E.L.S., E.T., C.-W.H., P.C., L.B.M., L.D.L.) and Biostatistics (S.K., Y.X.), School of Public Health, School of Kinesiology (E.T.), Institute for Social Research (P.C.), and Department of Neurology (L.B.M., L.D.L.), Michigan Medicine, University of Michigan, Ann Arbor.
| |
Collapse
|
27
|
Briceño EM, Mehdipanah R, Gonzales X, Heeringa S, Levine DA, Langa KM, Garcia N, Longoria R, Morgenstern LB. Methods and Early Recruitment of a Community-Based Study of Cognitive Impairment Among Mexican Americans and Non-Hispanic Whites: The BASIC-Cognitive Study. J Alzheimers Dis 2021; 73:185-196. [PMID: 31771059 DOI: 10.3233/jad-190761] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND As the Mexican American (MA) population grows and ages, there is an urgent need to estimate the prevalence of cognitive impairment or dementia (CID), cognitive trajectories, and identify community resource needs. The Brain Attack Surveillance in Corpus Christi (BASIC)-Cognitive project is a population-based study to address these issues among older MAs and non-Hispanic whites (NHW) and their informal care providers. OBJECTIVE Present the methodology and initial recruitment findings for the BASIC-Cognitive project. METHOD Random, door-to-door case ascertainment is used in Nueces County, Texas, to recruit community-dwelling and nursing home residents ≥65 and informal care providers. Households are identified from a two-stage area probability sample, using Census data to aim for equal balance of MAs and NHWs. Individuals with cognitive screens indicative of possible CID complete neuropsychological assessment (Harmonized Cognitive Assessment Protocol from the Health and Retirement Study). Informal care providers complete comprehensive interview and needs assessment. Study pairs repeat procedures at 2-year follow-up. Asset and concept mapping are performed to identify community resources and study care providers' perceptions of needs for individuals with CID. RESULTS 1,030 age-eligible households were identified, or 27% of households for whom age could be determined. 1,320 individuals were age-eligible, corresponding to 1.3 adults per eligible household. Initial recruitment yielded robust participation in the MA eligible population (60% of 689 individuals that completed cognitive screening). CONCLUSION The BASIC-Cognitive study will provide critical information regarding the prevalence of CID in MAs, the impact of caregiving, and allocation of community resources to meet the needs of this population.
Collapse
Affiliation(s)
- Emily M Briceño
- University of Michigan Medical School, Department of Physical Medicine & Rehabilitation, Ann Arbor, MI, USA
| | | | - Xavier Gonzales
- Texas A&M University, Department of Life Sciences, Corpus Christi, TX, USA
| | - Steven Heeringa
- University of Michigan Institute for Social Research, Ann Arbor, MI, USA
| | - Deborah A Levine
- University of Michigan Medical School, Department of Internal Medicine, Ann Arbor, MI, USA
| | - Kenneth M Langa
- University of Michigan Institute for Social Research, Ann Arbor, MI, USA.,University of Michigan Medical School, Department of Internal Medicine, Ann Arbor, MI, USA
| | - Nelda Garcia
- University of Michigan Medical School, Department of Neurology, Ann Arbor, MI, USA
| | - Ruth Longoria
- University of Michigan Medical School, Department of Neurology, Ann Arbor, MI, USA
| | - Lewis B Morgenstern
- University of Michigan, School of Public Health, Ann Arbor, MI, USA.,University of Michigan Medical School, Department of Neurology, Ann Arbor, MI, USA
| |
Collapse
|
28
|
Predicting Decreased Activities of Daily Living in Patients with Moyamoya Disease after Revascularization: Development and Assessment of a New Predictive Nomogram. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6624245. [PMID: 33997029 PMCID: PMC8105101 DOI: 10.1155/2021/6624245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
The aim of this study was to develop and validate a nomogram model to predict the risk of decreased activities of daily living (ADLs) in patients with moyamoya disease (MMD) following revascularization. The nomogram model was constructed based on data from 292 patients with MMD that were treated at Qilu Hospital of Shandong University from January 2018 to June 2019. The prediction model was assessed using a dataset of 119 patients with MMD collected from July 2019 to June 2020. Patients were evaluated with a general information questionnaire and the Mini Mental Status Examination, Hospital Anxiety and Depression Scale, Social Support Rating Scale, and ADL Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the features selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the prediction model were assessed using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis. Predictors contained in the nomogram included gender, age, monthly income, hypertension, and cognitive function and depression scores. The areas under the ROC curves of the training and testing datasets were 0.938 and 0.853, respectively. The prediction model displayed good calibration, and the decision curve analysis showed that it had a wide range of clinical applications. This novel predictive could be conveniently used to predict the risk of the decreased living activity ability in patients with MMD.
Collapse
|
29
|
Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3137] [Impact Index Per Article: 1045.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
30
|
Jiang X, Wang L, Morgenstern LB, Cigolle CT, Claflin ES, Lisabeth LD. New Index for Multiple Chronic Conditions Predicts Functional Outcome in Ischemic Stroke. Neurology 2021; 96:e42-e53. [PMID: 33024024 PMCID: PMC7884978 DOI: 10.1212/wnl.0000000000010992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 08/20/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine whether a new index for multiple chronic conditions (MCCs) predicts poststroke functional outcome (FO), we developed and internally validated the new MCC index in patients with ischemic stroke. METHODS A prospective cohort of patients with ischemic stroke (2008-2017) was interviewed at baseline and 90 days in the Brain Attack Surveillance in Corpus Christi Project. An average of 22 activities of daily living (ADL)/instrumental ADL (IADL) items measured the FO score (range 1-4) at 90 days. A FO score >3 (representing a lot of difficulty with ADL/IADLs) was considered unfavorable FO. A new index was developed using machine learning techniques to select and weight conditions and prestroke impairments. RESULTS Prestroke modified Rankin Scale (mRS) score, age, congestive heart failure (CHF), weight loss, diabetes, other neurologic disorders, and synergistic effects (dementia × age, CHF × renal failure, and prestroke mRS × prior stroke/TIA) were identified as important predictors in the MCC index. In the validation dataset, the index alone explained 31% of the variability in the FO score, was well-calibrated (p = 0.41), predicted unfavorable FO well (area under the receiver operating characteristic curve 0.81), and outperformed the modified Charlson Comorbidity Index in predicting the FO score and poststroke mRS. CONCLUSIONS A new MCC index was developed and internally validated to improve the prediction of poststroke FO. Novel predictors and synergistic interactions were identified. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in patients with ischemic stroke, an index for MCC predicts FO at 90 days.
Collapse
Affiliation(s)
- Xiaqing Jiang
- From the Departments of Epidemiology (X.J., L.B.M., L.D.L.) and Biostatistics (L.W.), School of Public Health, University of Michigan; Stroke Program (L.B.M., E.S.C., L.D.L.), Department of Family Medicine (C.T.C.), Department of Internal Medicine (C.T.C.), and Ann Arbor Healthcare System, Department of Physical Medicine and Rehabilitation (E.S.C.), University of Michigan Medical School; and VA Geriatric Research Education and Clinical Center (C.T.C.), Ann Arbor, MI
| | - Lu Wang
- From the Departments of Epidemiology (X.J., L.B.M., L.D.L.) and Biostatistics (L.W.), School of Public Health, University of Michigan; Stroke Program (L.B.M., E.S.C., L.D.L.), Department of Family Medicine (C.T.C.), Department of Internal Medicine (C.T.C.), and Ann Arbor Healthcare System, Department of Physical Medicine and Rehabilitation (E.S.C.), University of Michigan Medical School; and VA Geriatric Research Education and Clinical Center (C.T.C.), Ann Arbor, MI
| | - Lewis B Morgenstern
- From the Departments of Epidemiology (X.J., L.B.M., L.D.L.) and Biostatistics (L.W.), School of Public Health, University of Michigan; Stroke Program (L.B.M., E.S.C., L.D.L.), Department of Family Medicine (C.T.C.), Department of Internal Medicine (C.T.C.), and Ann Arbor Healthcare System, Department of Physical Medicine and Rehabilitation (E.S.C.), University of Michigan Medical School; and VA Geriatric Research Education and Clinical Center (C.T.C.), Ann Arbor, MI
| | - Christine T Cigolle
- From the Departments of Epidemiology (X.J., L.B.M., L.D.L.) and Biostatistics (L.W.), School of Public Health, University of Michigan; Stroke Program (L.B.M., E.S.C., L.D.L.), Department of Family Medicine (C.T.C.), Department of Internal Medicine (C.T.C.), and Ann Arbor Healthcare System, Department of Physical Medicine and Rehabilitation (E.S.C.), University of Michigan Medical School; and VA Geriatric Research Education and Clinical Center (C.T.C.), Ann Arbor, MI
| | - Edward S Claflin
- From the Departments of Epidemiology (X.J., L.B.M., L.D.L.) and Biostatistics (L.W.), School of Public Health, University of Michigan; Stroke Program (L.B.M., E.S.C., L.D.L.), Department of Family Medicine (C.T.C.), Department of Internal Medicine (C.T.C.), and Ann Arbor Healthcare System, Department of Physical Medicine and Rehabilitation (E.S.C.), University of Michigan Medical School; and VA Geriatric Research Education and Clinical Center (C.T.C.), Ann Arbor, MI
| | - Lynda D Lisabeth
- From the Departments of Epidemiology (X.J., L.B.M., L.D.L.) and Biostatistics (L.W.), School of Public Health, University of Michigan; Stroke Program (L.B.M., E.S.C., L.D.L.), Department of Family Medicine (C.T.C.), Department of Internal Medicine (C.T.C.), and Ann Arbor Healthcare System, Department of Physical Medicine and Rehabilitation (E.S.C.), University of Michigan Medical School; and VA Geriatric Research Education and Clinical Center (C.T.C.), Ann Arbor, MI.
| |
Collapse
|
31
|
Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke 2020; 51:3433-3439. [PMID: 33104471 DOI: 10.1161/strokeaha.120.030426] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We write this article amid a global pandemic and a heightened awareness of the underlying structural racism in the United States, unmasked by the recent killing of George Floyd and multiple other unarmed Black Americans (Spring 2020). Our purpose is to highlight the role of social determinants of health (SDOH) on stroke disparities, to inspire dialogue, to encourage research to deepen our understanding of the mechanism by which SDOH impact stroke outcomes, and to develop strategies to address SDOH and reduce stroke racial/ethnic disparities. We begin by defining SDOH and health disparities in today's context; we then move to discussing SDOH and stroke, particularly secondary stroke prevention, and conclude with possible approaches to addressing SDOH and reducing stroke disparities. These approaches include (1) building on prior work; (2) enhancing our understanding of populations and subpopulations, including intersectionality, of people who experience stroke disparities; (3) prioritizing populations and points along the stroke care continuum when racial/ethnic disparities are most prominent; (4) understanding how SDOH impact stroke disparities in order to test SDOH interventions that contribute to the disparity; (5) partnering with communities; and (6) exploring technological innovations. By building on the prior work and expanding efforts to address SDOH, we believe that stroke disparities can be reduced.
Collapse
Affiliation(s)
- Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.E.S.)
| | - Anjail Sharrief
- Stroke Institute, Department of Neurology, McGovern Medical School at University of Texas Health Sciences Center Houston (A.S.)
| | - Hannah Gardener
- Department of Neurology, University of Miami Miller School of Medicine, FL (H.G.)
| | - Carolyn Jenkins
- College of Nursing and Graduate Studies, Medical University of South Carolina (C.J.)
| | - Bernadette Boden-Albala
- Department of Population Health and Disease Prevention and Department of Epidemiology, University of California, Irvine (B.B.-A.)
| |
Collapse
|
32
|
Hollenhorst CN, Gibbs R, Kim S, Agyemang C, Lisabeth L, Morgenstern LB. Mexican American Immigrants Demonstrate Better Functional Stroke Outcomes Compared With Mexican American Nonimmigrants. Stroke 2020; 51:3129-3132. [PMID: 32867599 DOI: 10.1161/strokeaha.120.030915] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We analyzed differences in 90-day poststroke outcomes between Mexican Americans born in the United States (nonimmigrant) compared with those born outside the United States (immigrant). METHODS We performed a retrospective analysis of prospective data from the population-based Brain Attack Surveillance in Corpus Christi project. We identified stroke cases from 2008 to 2016 and quantified functional, cognitive, and neurological outcomes. Associations between outcome scores and immigration status were analyzed using weighted linear regression models. RESULTS Eighty-three Mexican American stroke cases (n=935) were immigrants, and 852 stroke cases were nonimmigrants. Average length of stay in the United States for immigrants was 47 years. Immigrants were older (69 versus 66 years), more likely men (60% versus 49%), had less education on average, and were more likely to have atrial fibrillation compared with nonimmigrants. No differences in other comorbidities existed between groups. After adjustment for confounders, immigrants had better functional outcomes (activities of daily living/instrumental activities of daily living; mean difference, -0.22; P=0.02; 1-4, higher scores worse) and no difference in neurological outcomes (log-National Institutes of Health Stroke Scale; mean difference, -0.15; P=0.15; 0-44, higher scores worse) or cognitive outcomes (3 Mini-Mental State Examination; mean difference, -0.79; P=0.64; 0-100, lower scores worse). CONCLUSIONS Long-term Mexican American immigrants in this community display better stroke functional outcomes than nonimmigrant Mexican Americans and comparable neurological and cognitive outcomes.
Collapse
Affiliation(s)
| | - River Gibbs
- University of Michigan School of Public Health, Ann Arbor (R.G., S.K., L.L., L.B.M.)
| | - Sehee Kim
- University of Michigan School of Public Health, Ann Arbor (R.G., S.K., L.L., L.B.M.)
| | - Charles Agyemang
- Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, the Netherlands (C.A.)
| | - Lynda Lisabeth
- University of Michigan Medical School, Ann Arbor (C.N.H., L.L., L.B.M.).,University of Michigan School of Public Health, Ann Arbor (R.G., S.K., L.L., L.B.M.)
| | - Lewis B Morgenstern
- University of Michigan Medical School, Ann Arbor (C.N.H., L.L., L.B.M.).,University of Michigan School of Public Health, Ann Arbor (R.G., S.K., L.L., L.B.M.)
| |
Collapse
|
33
|
Sozener CB, Lisabeth LD, Shafie-Khorassani F, Kim S, Zahuranec DB, Brown DL, Skolarus LE, Burke JF, Kerber KA, Meurer WJ, Case E, Morgenstern LB. Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites. Stroke 2020; 51:2428-2434. [PMID: 32673520 DOI: 10.1161/strokeaha.120.029376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study. METHODS Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms. RESULTS From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]). CONCLUSIONS Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.
Collapse
Affiliation(s)
- Cemal B Sozener
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.).,Department of Emergency Medicine, University of Michigan (C.B.S., W.J.M., L.B.M.)
| | - Lynda D Lisabeth
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.).,Department of Epidemiology (L.D.L., E.C., L.B.M.), School of Public Health, University of Michigan
| | | | - Sehee Kim
- Department of Biostatistics (F.S.-K., S.K.), School of Public Health, University of Michigan
| | - Darin B Zahuranec
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.)
| | - Devin L Brown
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.)
| | - Lesli E Skolarus
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.)
| | - James F Burke
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.)
| | - Kevin A Kerber
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.)
| | - William J Meurer
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.).,Department of Emergency Medicine, University of Michigan (C.B.S., W.J.M., L.B.M.)
| | - Erin Case
- Department of Epidemiology (L.D.L., E.C., L.B.M.), School of Public Health, University of Michigan
| | - Lewis B Morgenstern
- Stroke Program, University of Michigan Medical School (C.B.S., L.D.L., D.B.Z., D.L.B., L.E.S., J.F.B., K.A.K., W.J.M., L.B.M.).,Department of Emergency Medicine, University of Michigan (C.B.S., W.J.M., L.B.M.)
| |
Collapse
|
34
|
Dong L, Sánchez BN, Skolarus LE, Stulberg E, Morgenstern LB, Lisabeth LD. Sex difference in prevalence of depression after stroke. Neurology 2020; 94:e1973-e1983. [PMID: 32312890 PMCID: PMC7282882 DOI: 10.1212/wnl.0000000000009394] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/16/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE This study investigated the sex difference in prevalence of depression at 90 days after first-ever stroke. METHODS Patients with first-ever stroke (n = 786) were identified from the population-based Brain Attack Surveillance in Corpus Christi project (2011-2016). Poststroke depressive symptoms were assessed by the 8-item Patient Health Questionnaire, and prestroke depression status (history and medication use) was self-reported. Logistic regression was used to examine the association between sex and depression after stroke, and effect modification by prestroke depression status, accounting for missing data. RESULTS Women were more likely to have a history of and be on medication for depression at the time of stroke than men (p < 0.001). Prevalence of depression at 90 days was 28.2% for men (95% confidence interval [CI], 23.7%-32.8%) and 32.7% for women (95% CI, 27.8%-37.5%). The age-adjusted odds ratio (OR) of depression after stroke comparing women and men was 1.34 (95% CI, 0.97-1.85), and fully attenuated after adjustment for sociodemographic, stroke, and prestroke characteristics. Effect modification by prestroke depression status was present (p = 0.038). Among participants on medication for depression at the time of stroke, women were significantly less likely to have depression at 90 days compared with men (OR, 0.39; 95% CI, 0.16-0.96), whereas significant sex differences were not noted among those with and without a depression history. CONCLUSION The sex difference in prevalence of depression at 90 days after first-ever stroke was not significant overall, but varied by prestroke depression status. Interventions to address and prevent poststroke depression are needed, particularly among those with prestroke depression but not undergoing treatment for depression at stroke onset.
Collapse
Affiliation(s)
- Liming Dong
- From the Departments of Epidemiology (L.D., E.S., L.B.M., L.D.L.) and Biostatistics (B.N.S.), University of Michigan School of Public Health; and Stroke Program (L.E.S., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor.
| | - Brisa N Sánchez
- From the Departments of Epidemiology (L.D., E.S., L.B.M., L.D.L.) and Biostatistics (B.N.S.), University of Michigan School of Public Health; and Stroke Program (L.E.S., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor
| | - Lesli E Skolarus
- From the Departments of Epidemiology (L.D., E.S., L.B.M., L.D.L.) and Biostatistics (B.N.S.), University of Michigan School of Public Health; and Stroke Program (L.E.S., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor
| | - Eric Stulberg
- From the Departments of Epidemiology (L.D., E.S., L.B.M., L.D.L.) and Biostatistics (B.N.S.), University of Michigan School of Public Health; and Stroke Program (L.E.S., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor
| | - Lewis B Morgenstern
- From the Departments of Epidemiology (L.D., E.S., L.B.M., L.D.L.) and Biostatistics (B.N.S.), University of Michigan School of Public Health; and Stroke Program (L.E.S., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor
| | - Lynda D Lisabeth
- From the Departments of Epidemiology (L.D., E.S., L.B.M., L.D.L.) and Biostatistics (B.N.S.), University of Michigan School of Public Health; and Stroke Program (L.E.S., L.B.M., L.D.L.), University of Michigan Medical School, Ann Arbor
| |
Collapse
|
35
|
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4879] [Impact Index Per Article: 1219.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
36
|
Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5363] [Impact Index Per Article: 1072.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
37
|
Disparities in Health Care for Hispanic Patients in Physical Medicine and Rehabilitation in the United States. Am J Phys Med Rehabil 2019; 99:338-347. [DOI: 10.1097/phm.0000000000001342] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
38
|
Riva S, Mancini I, Maino A, Ferrari B, Artoni A, Agosti P, Peyvandi F. Long-term neuropsychological sequelae, emotional wellbeing and quality of life in patients with acquired thrombotic thrombocytopenic purpura. Haematologica 2019; 105:1957-1962. [PMID: 31558667 PMCID: PMC7327631 DOI: 10.3324/haematol.2019.226423] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/19/2019] [Indexed: 11/30/2022] Open
Abstract
Neurological symptoms related to microthrombosis are the hallmark of acute manifestations of acquired thrombotic thrombocytopenic purpura (TTP). Despite the achievement of hematological remission, patients may report persisting neurological impairment that affects their quality of life. To assess the long-term neuropsychological consequences of acute TTP, we recruited 35 acquired TTP patients (77% females, median age at onset 41 years, interquartile range: 35–48) regularly followed at our out-patient clinic of thrombotic microangiopathies in Milan (Italy) from December 2015 to October 2016. Patients underwent a psychological evaluation of memory and attentional functions, emotional wellbeing and health-related quality of life at least three months after their last acute TTP event (median 36 months, interquartile range: 17–54). During the psychological consultation, 17 patients (49%) referred persisting subjective neurological impairment in the frame of a remission phase, with at least one symptom as disorientation, loss of concentration, dizziness, lack of balance, headache and diplopia. Neuropsychological assessment revealed lower scores than the Italian general population pertaining to direct, indirect and deferred memory. A higher degree of impairment of memory domains was found in patients with neurological involvement at the time of presentation of the first acute TTP episode. Anxiety and depression were detected in seven (20%) and 15 (43%) patients, respectively. Health-related quality of life was lower than the Italian general population, with mental domains more impacted than physical domains (mean difference 58.43, 95% confidence interval: 71.49–45.37). Our study demonstrates compromised memory and attention functions, persisting anxiety/depression symptoms and a generally reduced quality of life in patients recovering from acute acquired TTP. New clinical strategies should be considered to improve these symptoms.
Collapse
Affiliation(s)
- Silvia Riva
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,St Mary's University, Twickenham, London, UK
| | - Ilaria Mancini
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - Alberto Maino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Azienda Provinciale per i Servizi Sanitari, Internal Medicine Unit, Trento, Italy
| | - Barbara Ferrari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Pasquale Agosti
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| |
Collapse
|
39
|
Stulberg EL, Dong L, Zheutlin AR, Kim S, Claflin ES, Skolarus LE, Morgenstern LB, Lisabeth LD. Associations of Self-Reported History of Depression and Antidepressant Use Before Stroke Onset With Poststroke Post-Acute Rehabilitation Care-An Exploratory Study: The BASIC (Brain Attack Surveillance in Corpus Christi) Project. J Am Heart Assoc 2019; 8:e013382. [PMID: 31423875 PMCID: PMC6759886 DOI: 10.1161/jaha.119.013382] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Prestroke depression status and post–acute rehabilitation care (PARC) are determinants of poststroke depression and function. However, little is known on how prestroke depression status affects PARC placement, a possible pathway for upstream intervention. We examined how prestroke depression status affects PARC in a population‐based study. Methods and Results Incident ischemic stroke cases were from the BASIC (Brain Attack Surveillance in Corpus Christi) Project from 2008 to 2012. Prestroke depression status was self‐reported and categorized as (1) never depressed, (2) history of depression without antidepressant use before stroke onset, or (3) antidepressant use before stroke onset. PARC included home, a skilled nursing facility, or an inpatient rehabilitation facility. Confounder‐adjusted multinomial regression models were used to examine the association between prestroke depression status and PARC. Adjustment for stroke severity was deferred in the main analyses because it may lie on the causal pathway. There were 548 stroke survivors (mean age 65.3 years, 48.3% female, 62.6% Mexican‐American). The adjusted odds ratios comparing home discharge to a skilled nursing facility were 1.88 (95% CI: 0.86‐4.11) for those with a history of depression and 2.55 (95% CI: 1.11‐5.83) for those using an antidepressant at stroke onset, relative to those never depressed. The adjusted odds ratios comparing an inpatient rehabilitation facility to a skilled nursing facility were 1.17 (95% CI 0.40‐3.42) and 3.28 (95% CI 1.24‐8.67) for those with a history of depression and those using an antidepressant at stroke onset, respectively, relative to those never depressed. Conclusions Antidepressant use before stroke onset may increase odds of home and inpatient rehabilitation facility discharge compared with skilled nursing facility discharge.
Collapse
Affiliation(s)
- Eric L Stulberg
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,Northwestern University Feinberg School of Medicine Chicago IL
| | - Liming Dong
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI
| | - Alexander R Zheutlin
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,University of Michigan School of Medicine Ann Arbor MI
| | - Sehee Kim
- Department of Biostatistics University of Michigan School of Public Health Ann Arbor MI
| | - Edward S Claflin
- Department of Physical Medicine and Rehabilitation University of Michigan School of Medicine Ann Arbor MI
| | - Lesli E Skolarus
- Department of Neurology University of Michigan School of Medicine Ann Arbor MI
| | - Lewis B Morgenstern
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,Department of Neurology University of Michigan School of Medicine Ann Arbor MI
| | - Lynda D Lisabeth
- Department of Epidemiology University of Michigan School of Public Health Ann Arbor MI.,Department of Neurology University of Michigan School of Medicine Ann Arbor MI
| |
Collapse
|
40
|
Lisabeth LD, Sánchez BN, Lim D, Chervin RD, Case E, Morgenstern LB, Tower S, Brown DL. Sleep-disordered breathing and poststroke outcomes. Ann Neurol 2019; 86:241-250. [PMID: 31155749 PMCID: PMC7549189 DOI: 10.1002/ana.25515] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the association between sleep-disordered breathing and stroke outcomes, and determine the contribution of sleep-disordered breathing to outcome disparities in Mexican Americans. METHODS Ischemic stroke patients (n = 995), identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2015), were offered participation in a sleep-disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep-disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep-disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health-risk behaviors, stroke severity, and vascular risk factors. RESULTS Median age was 67 years (interquartile range [IQR] = 59-78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6-25); 62.8% had sleep-disordered breathing. Sleep-disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval [CI] = 0.01-0.28) and cognitive outcome (mean difference in modified Mini-Mental State Examination = -2.66, 95% CI = -4.85 to -0.47) but not neurologic or quality of life outcomes. Sleep-disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = -3.97, 95% CI = -6.63 to -1.31) than non-Hispanic whites (β = -0.40, 95% CI = -4.18 to 3.39, p-interaction = 0.15). INTERPRETATION Sleep-disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep-disordered breathing treatment in stroke. If effective, sleep-disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241-250.
Collapse
Affiliation(s)
- Lynda D Lisabeth
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
- Stroke Program, University of Michigan Health System, Ann Arbor, MI
| | - Brisa N Sánchez
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - David Lim
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Ronald D Chervin
- Michael S. Aldrich Sleep Disorders Laboratory, University of Michigan Health System, Ann Arbor, MI
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lewis B Morgenstern
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
- Stroke Program, University of Michigan Health System, Ann Arbor, MI
| | | | - Devin L Brown
- Stroke Program, University of Michigan Health System, Ann Arbor, MI
| |
Collapse
|
41
|
Dong L, Sánchez BN, Skolarus LE, Morgenstern LB, Lisabeth LD. Ethnic Differences in Prevalence of Post-stroke Depression. Circ Cardiovasc Qual Outcomes 2019; 11:e004222. [PMID: 29371220 DOI: 10.1161/circoutcomes.117.004222] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/21/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about ethnic differences in poststroke depression (PSD) in the United States. This study aims to estimate the prevalence of PSD at 90 days after first-ever stroke and to examine ethnic differences in the prevalence between Mexican Americans (MAs) and non-Hispanic whites (NHWs). METHODS AND RESULTS Stroke cases from 2011 to 2015 were identified from the BASIC project (Brain Attack Surveillance in Corpus Christi)-a population-based stroke surveillance study in south Texas. Participants were interviewed at the onset of stroke (baseline interview) and ≈90 days post-stroke (outcome interview). PSD was assessed by the Patient Health Questionnaire-8. Inverse probability weights were generated to account for differential attrition, and weighted logistic regression was used to investigate the association between ethnicity and PSD. The study sample consisted of 586 first-ever stroke patients who completed nonproxy baseline and outcome interviews and had depression assessment. Approximately, 60% of them were MAs, and 40% were NHWs. After accounting for attrition, the prevalence of depression at 90 days post-stroke was 30.4% for MAs (95% confidence interval, 25.0%-35.9%) and 20.7% for NHWs (95% confidence interval, 15.7%-25.7%). The crude odds of PSD in MAs was 1.69 times greater than that in NHWs (95% confidence interval, 1.13-2.51). The odds ratio decreased by 23.6% after adjustment for education (odds ratio, 1.29; 95% confidence interval, 0.82-2.02) and was further attenuated with additional adjustment for other covariates. CONCLUSIONS MAs had a higher prevalence of PSD at 90 days than NHWs. The ethnic difference was explained by sociodemographic and health factors, especially low educational attainment.
Collapse
Affiliation(s)
- Liming Dong
- From the Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Brisa N Sánchez
- From the Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Lesli E Skolarus
- From the Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lewis B Morgenstern
- From the Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Lynda D Lisabeth
- From the Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| |
Collapse
|
42
|
Chi NF, Chao SP, Huang LK, Chan L, Chen YR, Chiou HY, Hu CJ. Plasma Amyloid Beta and Tau Levels Are Predictors of Post-stroke Cognitive Impairment: A Longitudinal Study. Front Neurol 2019; 10:715. [PMID: 31312178 PMCID: PMC6614443 DOI: 10.3389/fneur.2019.00715] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/17/2019] [Indexed: 01/24/2023] Open
Abstract
Objectives: Post-stroke cognitive impairment (PSCI) is a common disease that may occur within 3 months after a stroke or even later. However, the mechanism of PSCI development is unclear. The present study investigated whether the levels of plasma amyloid beta-42 (Aβ42) and tau are associated with the onset of PSCI. Methods: Fifty-five patients admitted within 7 days of acute ischemic stroke were enrolled and followed up for 1 year. Montreal Cognitive Assessment (MoCA) was administered at 3 months and 1 year, and plasma Aβ42 and tau levels were determined using an ultrasensitive immunoassay (immunomagnetic reduction) within 7 days of the stroke event and 3 months later. Results: In this study, 13 of 55 patients developed PSCI (MoCA score <23) at 3 months. Seven patients with PSCI at 3 months recovered to a cognitively normal state at 1 year, whereas seven cognitively normal patients developed PSCI at 1 year. The patients with PSCI at 1 year had a higher incidence of cognitive function deterioration between 3 months and 1 year compared with those without PSCI at 1 year. Plasma Aβ42 and tau levels at 3 months were lower in the patients with PSCI at 1 year than in those without PSCI (Aβ42: 15.1 vs. 17.2 pg/mL, P = 0.013; tau: 16.7 vs. 19.9 pg/mL, P = 0.018). Low education levels and pre-existing white matter disease were the most significant predictors of PSCI at 3 months, and poor cognitive performance at 3 months and low plasma Aβ42 and tau levels at 3 months were the most significant predictors of PSCI at 1 year. Conclusion: The pathogenesis of PSCI is complex and changes with time. Ischemia-induced Aβ42/tau pathology might be involved in PSCI development.
Collapse
Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan.,Department of Neurology, Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Ping Chao
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Li-Kai Huang
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Lung Chan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
| | - Yih-Ru Chen
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Stroke Center, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan.,Graduate Institute of Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
43
|
Bailoor K, Shafie-Khorassani F, Lank RJ, Case E, Garcia NM, Lisabeth LD, Sánchez BN, Kim S, Morgenstern LB, Zahuranec DB. Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke. Stroke 2019; 50:1641-1647. [PMID: 31177986 DOI: 10.1161/strokeaha.118.024460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (≤24 hours) and late (>24 hours) DNR. Stroke type-specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results- Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06-3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50-0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04-0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P>0.60). Conclusions- Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.
Collapse
Affiliation(s)
- Kunal Bailoor
- From the Department of Internal Medicine (K.B.), Michigan Medicine, Ann Arbor
| | - Fatema Shafie-Khorassani
- Department of Biostatistics (F.S.-K., B.N.S., S.K.), University of Michigan School of Public Health, Ann Arbor
| | - Rebecca J Lank
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor
| | - Erin Case
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor.,Department of Epidemiology (E.C., L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor
| | - Nelda M Garcia
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor
| | - Lynda D Lisabeth
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor.,Department of Epidemiology (E.C., L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor
| | - Brisa N Sánchez
- Department of Biostatistics (F.S.-K., B.N.S., S.K.), University of Michigan School of Public Health, Ann Arbor
| | - Sehee Kim
- Department of Biostatistics (F.S.-K., B.N.S., S.K.), University of Michigan School of Public Health, Ann Arbor
| | - Lewis B Morgenstern
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor.,Department of Epidemiology (E.C., L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor
| | - Darin B Zahuranec
- Stroke Program (R.J.L., E.C., N.M.G., L.D.L., L.B.M., D.B.Z.), Michigan Medicine, Ann Arbor
| |
Collapse
|
44
|
The prevalence of disability among people with cancer, cardiovascular disease, chronic respiratory disease and/or diabetes: a systematic review. INT J EVID-BASED HEA 2019; 16:154-166. [PMID: 29608458 DOI: 10.1097/xeb.0000000000000138] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD), cancer, diabetes and chronic respiratory disease are noncommunicable diseases (NCDs) that cause extensive social and economic burden worldwide, particularly in low-income and middle-income countries. There is growing recognition of the importance of the disabilities that individuals experience as a consequence of these NCDs. OBJECTIVES This systematic review examined the prevalence of disabilities associated with cancer, CVD, chronic respiratory disease and diabetes. METHODS A comprehensive literature search was conducted in PubMed, CINAHL, Embase, Web of Science, PsycINFO, CIRRIE, WHO database, LILACS and AIM. Studies were included if their samples were representative of people with at least one of these four conditions and if prevalence estimates of disability were provided. As random sampling was not feasible in the majority of cases, studies were included where they offered evidence that their sample was representative of the general population being investigated. RESULTS A total of 105 articles were included in the review. Most studies were conducted in high-income countries. The prevalence of difficulties with activities of daily living (i.e. eating, bathing, dressing) was reported to be 10.4-34.5% amongst cancer survivors, 21.1-64.1% in those with CVD, 7.4-49.8% in those with chronic respiratory disease and 12.2-54.5% for those with diabetes. The prevalence of a range of other physical, cognitive and psychological impairments (systemic or structural) was additionally described for each disease. CONCLUSION Substantial proportions of people with cancer, CVD, chronic respiratory disease or diabetes experience some form of disability - although there was great variance in prevalence and definitions. The findings of this review support the evidence base of global impact associated with NCD, indicate frequency measures for specific disabilities and inabilities associated with each NCD and provide direction for future systematic reviews. WHAT IS KNOWN ABOUT THE TOPIC WHAT THIS ARTICLE ADDS.
Collapse
|
45
|
Burns SP, Mueller M, Magwood G, White BM, Lackland D, Ellis C. Racial and ethnic differences in post-stroke subjective cognitive decline exist. Disabil Health J 2019; 12:87-92. [PMID: 30115583 DOI: 10.1016/j.dhjo.2018.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Racial and ethnic minorities consistently demonstrate disparate post-stroke outcomes. However, there is a paucity of literature related to whether this disparity exists specifically in post-stroke cognitive decline. OBJECTIVE To determine if racial and ethnic disparities exist in post-stroke subjective cognitive decline (SCD) among non-Hispanic Blacks (Blacks), American Indians or Alaska Natives (AI/ANs), Hispanics, and non-Hispanic Whites (Whites) in the United States using data from the Behavioral Risk Factor Surveillance System (BRFSS). METHODS A retrospective analysis was completed using the 2016 BRFSS data in adults who self-reported stroke and SCD. Descriptive statistics were completed for baseline comparisons using chi squared tests for categorical variables. A binary logistic regression controlling for baseline differences was completed to examine racial and ethnic differences in SCD. RESULTS Significant differences in SCD were identified across all racial and ethnic groups. When compared to Whites, Blacks, AI/ANs, and Hispanics more frequently reported worsening confusion or memory loss that interfered with day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home. AI/ANs who reported SCD were more likely than Whites to have help available. Hispanic persons with SCD or their family members were most likely to discuss SCD with a healthcare provider. CONCLUSION Although persons from all racial and ethnic groups in this study experienced some degree of SCD, Blacks, AI/ANs, and Hispanics most frequently reported worsening confusion or memory loss impacting engagement in day-to-day activities and the ability to work, volunteer, and engage in social activities outside of the home.
Collapse
Affiliation(s)
- Suzanne Perea Burns
- WISSDOM Center, Medical University of South Carolina, Charleston, USA; School of Occupational Therapy, Texas Woman's University, Denton, USA.
| | - Martina Mueller
- WISSDOM Center, Medical University of South Carolina, Charleston, USA; College of Nursing, Medical University of South Carolina, Charleston, USA
| | - Gayenell Magwood
- WISSDOM Center, Medical University of South Carolina, Charleston, USA; College of Nursing, Medical University of South Carolina, Charleston, USA
| | - Brandi M White
- Division of Health Sciences, Education, and Research, University of Kentucky, Lexington, USA
| | - Daniel Lackland
- Department of Neurology, Medical University of South Carolina, Charleston, USA
| | - Charles Ellis
- Department of Communication Sciences and Disorders, East Carolina University, Greenville, USA
| |
Collapse
|
46
|
Musa KI, Keegan TJ. The change of Barthel Index scores from the time of discharge until 3-month post-discharge among acute stroke patients in Malaysia: A random intercept model. PLoS One 2018; 13:e0208594. [PMID: 30571691 PMCID: PMC6301695 DOI: 10.1371/journal.pone.0208594] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 11/20/2018] [Indexed: 02/05/2023] Open
Abstract
Background Acute stroke results in functional disability measurable using the well-known Barthel Index. The objectives of the study are to describe the change in the Barthel Index score and to model the prognostic factors for Barthel Index change from discharge up to 3 months post-discharge using the random intercept model among patients with acute first ever stroke in Kelantan, Malaysia. Methods A total 98 in-hospital first ever acute stroke patients were recruited, and their Barthel Index scores were measured at the time of discharge, at 1 month and 3 months post-discharge. The Barthel Index was scored through telephone interviews. We employed the random intercept model from linear mixed effect regression to model the change of Barthel Index scores during the three months intervals. The prognostic factors included in the model were acute stroke subtypes, age, sex and time of measurement (at discharge, at 1 month and at 3 month post-discharge). Results The crude mean Barthel Index scores showed an increased trend. The crude mean Barthel Index at the time of discharge, at 1-month post-discharge and 3 months post-discharge were 35.1 (SD = 39.4), 64.4 (SD = 39.5) and 68.8 (SD = 38.9) respectively. Over the same period, the adjusted mean Barthel Index scores estimated from the linear mixed effect model increased from 39.6 to 66.9 to 73.2. The adjusted mean Barthel Index scores decreased as the age increased, and haemorrhagic stroke patients had lower adjusted mean Barthel Index scores compared to the ischaemic stroke patients. Conclusion Overall, the crude and adjusted mean Barthel Index scores increase from the time of discharge up to 3-month post-discharge among acute stroke patients. Time after discharge, age and stroke subtypes are the significant prognostic factors for Barthel Index score changes over the period of 3 months.
Collapse
Affiliation(s)
- Kamarul Imran Musa
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kbg Kerian, Kelantan, Malaysia
- * E-mail:
| | - Thomas J. Keegan
- The Centre for Health Informatics, Computing, and Statistics (CHICAS), Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| |
Collapse
|
47
|
Li C, Baek J, Sanchez BN, Morgenstern LB, Lisabeth LD. Temporal trends in age at ischemic stroke onset by ethnicity. Ann Epidemiol 2018; 28:686-690.e2. [PMID: 30087013 PMCID: PMC6162154 DOI: 10.1016/j.annepidem.2018.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 06/11/2018] [Accepted: 07/18/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE To explore temporal trends in age at first-ever ischemic stroke onset in a bi-ethnic, population-based study. METHODS Cases of first-ever ischemic stroke (n = 3252) were identified in the Brain Attack Surveillance in Corpus Christi Project (2000-2012). Demographics and risk factors were abstracted from medical records. Trends in age at stroke onset were assessed overall and by ethnicity (Mexican American [MA] and non-Hispanic white [NHW]) using generalized additive models. Differences by ethnicity were tested by including an interaction term between time and ethnicity. Models were run unadjusted and adjusted for age of the population at risk for stroke. RESULTS Mean age at first-ever ischemic stroke significantly decreased from an average of 71.7 years in 2000 to an average of 69.3 years in 2012 (p = .0043). Ethnicity significantly modified the temporal trends (p < .001) with declines greater in NHWs than in MAs; mean age was estimated to decrease from 74.8 to 71.3 over the 13 years for NHWs, whereas for MAs, mean age was estimated to decrease from 68.9 to 66.9 after adjusting for ethnic-specific average age of the population at risk. CONCLUSIONS Average age at first-ever stroke onset declined over time in this community. Efforts should be made to prevent stroke by controlling risk factors before and during midlife.
Collapse
Affiliation(s)
- Chengwei Li
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
| | - Jonggyu Baek
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Brisa N Sanchez
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Lewis B Morgenstern
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor; Stroke Program, University of Michigan, Ann Arbor
| | - Lynda D Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor; Stroke Program, University of Michigan, Ann Arbor.
| |
Collapse
|
48
|
Lisabeth LD, Horn SD, Ifejika NL, Sais E, Fuentes M, Jiang X, Case E, Morgenstern LB. The difficulty of studying race-ethnic stroke rehabilitation disparities in a community. Top Stroke Rehabil 2018; 25:393-396. [PMID: 30187831 DOI: 10.1080/10749357.2018.1481606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Minority populations have worse stroke outcomes compared with non-Hispanic whites (NHWs). One possible explanation for this disparity is differential allocation of stroke rehabilitation. We utilized a population-based stroke study to determine the feasibility of studying Mexican American-NHW differences in stroke rehabilitation in a population-based design including identification of community partners, development of standardized data collection instruments, and collection of pilot data. METHODS As part of the Brain Attack Surveillance in Corpus Christi project, we followed 48 patients for the first 90 days after stroke, and attempted to work with community partners to garner information on rehabilitation modalities used. With input from local occupational and physical therapists and speech language pathologists, we created data collection forms to capture rehabilitation activities and time spent on these activities and conducted a 3-month data collection pilot. RESULTS Of the 79 rehabilitation venues in the community, 63 (80%) agreed to participate. During the pilot, 545 data forms from 20 stroke patients were collected corresponding to ~18% of stroke patients. Forms were used by 13 partners during the pilot including 3 of 4 inpatient rehabilitation facilities, 4 of 13 skilled nursing facilities, 4 of 26 home health agencies, and 2 of 36 outpatient rehabilitation providers. CONCLUSIONS Initial agreement from rehabilitation providers to participate in research was excellent, but completion of study related data collection forms was sub-optimal suggesting this approach is not feasible for a future population-based stroke rehabilitation study. Further methods to study post-stroke rehabilitation disparities in communities are needed.
Collapse
Affiliation(s)
- Lynda D Lisabeth
- a Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor , MI , USA
| | - Susan D Horn
- b Departments of Biomedical Informatics and Population Health Sciences , University of Utah Medical School , Salt Lake City , UT , USA
| | - Nneka L Ifejika
- c Department of Neurology , McGovern Medical School at UTHealth , Houston , TX , USA
| | - Emma Sais
- d Stroke Program , University of Michigan Medical School , Ann Arbor , MI , USA
| | - Michael Fuentes
- e Corpus Christi Rehabilitation Hospital , Corpus Christi , TX , USA
| | - Xiaqing Jiang
- a Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor , MI , USA
| | - Erin Case
- a Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor , MI , USA
| | - Lewis B Morgenstern
- d Stroke Program , University of Michigan Medical School , Ann Arbor , MI , USA
| |
Collapse
|
49
|
White CL, Cantu A, Motz D, Patterson M, Caron JL, Birnbaum LA. Opportunities and challenges in secondary stroke prevention: a mixed methods study. Disabil Rehabil 2018; 41:3192-3197. [PMID: 30041552 DOI: 10.1080/09638288.2018.1492029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To describe control of risk factors after stroke from the perspectives of the stroke survivor, the family, and healthcare professionals.Materials and methods: A mixed methods design was used, undertaken in two phases: i) qualitative study using focus group methodology to explore secondary stroke prevention and ii) survey of stroke survivors about use of technology and self-management of blood pressure (BP).Results: From the eight focus groups (n = 33), three themes were identified: i) stroke is a wake-up call to do the right things; ii) challenges to doing the right things; and iii) role of technology in helping you to do the right things. Among survey respondents (n = 82), most participants reported mobile phone ownership (93%), mostly smartphones (66%), and >80% identified a greater role for technology in supporting management of risk factors. Participants who reported monitoring BP at home were significantly more likely to know their target BP than those not monitoring at home (83 vs. 42%; p < 0.001) and more adherent with medications (78 vs. 52%; p = 0.016).Conclusions: These findings highlight the ongoing challenges with achieving risk factor control after stroke and the potential to utilise health information technology to engage stroke survivors in self-management of their risk factors.Implications for rehabilitationClinicians should be knowledgeable of the challenges that stroke survivors face in managing their risk factors after stroke and the role that they can play in providing tailored education.BP continues to be poorly controlled after stroke and there is opportunity for improvement.Stroke survivors and their families are receptive to using health information technology to support their risk factor control.Rehabilitation clinicians have an opportunity to incorporate different aspects of health information technology into their practice to support self-management of risk factors.
Collapse
Affiliation(s)
- Carole L White
- School of Nursing, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
| | - Adelita Cantu
- School of Nursing, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
| | - Deb Motz
- Baptist Health System, San Antonio, TX, USA
| | | | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
| | - Lee A Birnbaum
- Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
| |
Collapse
|
50
|
Reeves M, Lisabeth L, Williams L, Katzan I, Kapral M, Deutsch A, Prvu-Bettger J. Patient-Reported Outcome Measures (PROMs) for Acute Stroke: Rationale, Methods and Future Directions. Stroke 2018; 49:1549-1556. [DOI: 10.1161/strokeaha.117.018912] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Mathew Reeves
- From the Department of Epidemiology, Michigan State University, East Lansing (M.R.)
| | - Lynda Lisabeth
- School of Public Health, University of Michigan, Ann Arbor (L.L.)
| | | | - Irene Katzan
- Neurological Institute, Cleveland Clinic, OH (I.K.)
| | - Moira Kapral
- Division of General Internal Medicine, Department of Medicine, University of Toronto, ON, Canada (M.K.)
| | - Anne Deutsch
- Shirley Ryan AbilityLab, Northwestern University, Chicago, IL (A.D.)
| | | |
Collapse
|