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

Moderating Effects of Informal Care on the Relationship Between ADL Limitations and Adverse Outcomes in Stroke Survivors

BACKGROUND

Stroke survivors with limitations in activities of daily living (ADL) have a greater risk of experiencing falls, hospitalizations, or physical function decline. We examined how informal caregiving received in hours per week by stroke survivors moderated the relationship between ADL limitations and adverse outcomes.

METHODS

In this retrospective cohort, community-dwelling participants were extracted from the National Health and Aging Trends Study (2011-2020; n=277) and included if they had at least 1 formal or informal caregiver and reported an incident stroke in the prior year. Participants reported the amount of informal caregiving received in the month prior (low [<5.8], moderate [5.8-27.1], and high [27.2-350.4] hours per week) and their number of ADL limitations (ranging from 0 to 7). Participants were surveyed 1 year later to determine the number of adverse outcomes (ie, falls, hospitalizations, and physical function decline) experienced over the year. Poisson regression coefficients were converted to average marginal effects and estimated the moderating effects of informal caregiving hours per week on the relationship between ADL limitations and adverse outcomes.

RESULTS

Stroke survivors were 69.7% White, 54.5% female, with an average age of 80.5 (SD, 7.6) years and 1.2 adverse outcomes at 2 years after the incident stroke. The relationships between informal caregiving hours and adverse outcomes and between ADL limitations and adverse outcomes were positive. The interaction between informal caregiving hours per week and ADL limitations indicated that those who received the lowest amount of informal caregiving had a rate of 0.12 more adverse outcomes per ADL (average marginal effect, 0.12 [95% CI, 0.005-0.23]; P=0.041) than those who received the highest amounts.

CONCLUSIONS

Informal caregiving hours moderated the relationship between ADL limitations and adverse outcomes in this sample of community-based stroke survivors. Higher amounts relative to lower amounts of informal caregiving hours per week may be protective by decreasing the rate of adverse outcomes per ADL limitation.

Racial and Ethnic Disparities in Neurological Care in the United States

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.

Evaluations of virtual exercise programmes for adults with mobility limitations: a scoping review protocol incorporating an equity lens to inform the development of strategies to optimise participation of under-represented groups

INTRODUCTION

For individuals with mobility limitations, virtual exercise programmes can address the challenges of in-person participation in community exercise programmes. A synthesis of studies of virtual exercise programmes targeting mobility limitations provided outside of conventional rehabilitation services and strategies used to optimise equitable access and inclusivity in these programmes is lacking. We aim to characterise evaluations of virtual exercise programmes for adults with mobility limitations, and the nature of and extent to which equity, diversity and inclusion considerations are integrated in the research process.

METHODS AND ANALYSIS

A scoping review following a six-stage methodological framework, including a consultation exercise, is proposed. A comprehensive strategy will be used to search Medline, Embase, PEDro, CINAHL and Scopus to identify peer-reviewed studies evaluating virtual exercise programmes for adults with mobility limitations living in the community. Three trained reviewers will select studies independently. Data (eg, study methodology, programme structure and content, participant characteristics) will be extracted using a standardised form, and collated and summarised using quantitative and qualitative methods. The PROGRESS-Plus and International Classification of Functioning, Disability and Health frameworks will be used to classify participant characteristics and study outcomes, respectively. During the consultation exercise, key knowledge users, including exercise participants, programme providers and coordinators, and members of community organisations for persons living with disabilities and under-represented groups, will be asked to provide insights regarding the applicability of review findings. A directed content analysis of data from the consultation exercise will be performed.

ETHICS AND DISSEMINATION

The research ethics board at the University of Toronto approved the consultation exercise. Findings will be disseminated through peer-reviewed publications and conference presentations. Findings will enhance understanding of current research evaluating virtual exercise programmes and inform future research and strategies for promoting equitable access and outcomes for individuals with mobility limitations.

REGISTRATION DETAILS

https://doi.org/10.17605/OSF.IO/X5JMA.

Racial Disparities in Utilization of Emergency Medical Services and Related Impact on Poststroke Disability

BACKGROUND

Prompt seeking of emergency medical services (EMS) assistance at stroke onset is critical to minimize poststroke disability.

OBJECTIVE

The aim was to study how racial differences in EMS decision-relevant factors and EMS use impact stroke care and disability outcomes.

DESIGN

A prospective observational study.

PARTICIPANTS

A total of 1168 acute ischemic stroke patients discharged from April 2016 to October 2017 at a safety net hospital were included; 108 patients were surveyed before discharge.

MEASURES

(1) Prehospital delay: EMS use, timely hospital arrival; (2) Stroke care: alteplase receipt and inpatient rehab; (3) Outcomes: Functional improvement at discharge (admission minus discharge scores on National Institutes of Health Stroke Scale), 90-day modified Rankin Scale; (4) EMS decision-relevant factors: Stroke symptom knowledge, source of knowledge, unfavorable past EMS/care experiences, and financial barriers to EMS use.

RESULTS

Despite more Black patients using EMS than Whites/Asians (56% vs. 48%, P =0.003), their timely hospital arrival was 30% less likely. Adjusted for stroke severity, receipt of alteplase, and inpatient rehab were similar, but Black patients fared worse on functional improvement at discharge (among severe strokes, 2.4 National Institutes of Health Stroke Scale points less improvement, P <0.01), and on functional normalcy at 90 days (modified Rankin Scale score 0-1 being 60% less likely across severity categories) ( P <0.01). Fewer Black patients knew any stroke symptoms before the stroke (72% vs. 87%, P =0.03), and fewer learned about stroke from providers ( P =0.01). Financial barriers and provider mistrust were similar.

CONCLUSIONS

Black patients had less knowledge of stroke symptoms, more care-seeking delay, and poorer outcomes. Including stroke education as a standard of chronic disease care may mitigate stroke outcome disparities.

Was COVID-19 Associated With Worsening Inequities in Stroke Treatment and Outcomes?

Background COVID-19 stressed hospitals and may have disproportionately affected the stroke outcomes and treatment of Black and Hispanic individuals. Methods and Results This retrospective study used 100% Medicare Provider Analysis and Review file data from between 2016 and 2020. We used interrupted time series analyses to examine whether the COVID-19 pandemic exacerbated disparities in stroke outcomes and reperfusion therapy. Among 1 142 560 hospitalizations for acute ischemic strokes, 90 912 (8.0%) were Hispanic individuals; 162 752 (14.2%) were non-Hispanic Black individuals; and 888 896 (77.8%) were non-Hispanic White individuals. The adjusted odds of mortality increased by 51% (adjusted odds ratio [aOR], 1.51 [95% CI, 1.34-1.69]; P<0.001), whereas the rates of nonhome discharges decreased by 11% (aOR, 0.89 [95% CI, 0.82-0.96]; P=0.003) for patients hospitalized during weeks when the hospital's proportion of patients with COVID-19 was >30%. The overall rates of motor deficits (P=0.25) did not increase, and the rates of reperfusion therapy did not decrease as the weekly COVID-19 burden increased. Black patients had lower 30-day mortality (aOR, 0.70 [95% CI, 0.69-0.72]; P<0.001) but higher rates of motor deficits (aOR, 1.14 [95% CI, 1.12-1.16]; P<0.001) than White individuals. Hispanic patients had lower 30-day mortality and similar rates of motor deficits compared with White individuals. There was no differential increase in adverse outcomes or reduction in reperfusion therapy among Black and Hispanic individuals compared with White individuals as the weekly COVID-19 burden increased. Conclusions This national study of Medicare patients found no evidence that the hospital COVID-19 burden exacerbated disparities in treatment and outcomes for Black and Hispanic individuals admitted with an acute ischemic stroke.

Black Americans have worse stroke outcome compared with non-Hispanic whites

INTRODUCTION

We studied racial differences in post-stroke outcomes using a prospective, population-based cohort of stroke survivors as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project.

METHODS

Neurologic (NIHSS, range of 0-42, higher scores are worse), functional (ADLs/IADLs, range 1-4, higher scores are worse), and cognitive (3MSE, range 0-100, higher scores are better) outcomes were measured 90 days after stroke. Cox proportional hazards and negative binomial linear regression models were used to examine the associations between race and 90-day all-cause mortality and NIHSS, respectively, whereas linear regression was used for ADLs/IADLs and 3MSE scores. Covariates included demographics, initial NIHSS, comorbidities, prior stroke history, tPA treatment status, pre-stroke disability, and pre-stroke cognition. The mortality model was also adjusted for DNR status.

RESULTS

At 90 days post-stroke, Black American individuals (BAs) (n = 122) had a median (IQR) NIHSS of 2 (1,6) compared to NIHSS of 1 (0,3) in non-Hispanic White American individuals (NHWs) (n = 795). BAs had a median (IQR) ADL/IADL score of 2.41 (1.50, 3.39) compared to 2.00 (1.27, 2.95) in NHWs. BAs scored a median of 84 (75, 92) on the 3MSE compared to NHWs' score of 91.5 (83, 96). Death occurred in 23 (8%) of BAs and 268 (15%) of NHWs within 90 days among those who participated in baseline. After adjustment for covariates, functional outcomes at 90 days were worse in BAs compared to NHWs, with 15.8% (95% CI=5.2, 26.4) greater limitations in ADLs/IADLs and 43.9% (95% CI=12.0, 84.9) greater severity of stroke symptoms. Cognition at 90 days was 6.5% (95% CI=2.4, 10.6) lower in BAs compared to NHWs. BAs had a 35.4% lower (95% CI=-9.8, 61.9) hazard rate of mortality than NHWs.

CONCLUSIONS

In this prospective, population-based community sample, BAs had worse neurologic, functional and cognitive outcomes at 90 days compared to NHWs. Future research should investigate how social determinants of health including structural racism, neighborhood factors and access to preventive and recovery services influences these racial disparities.

Determinants of Inequities in Neurologic Disease, Health, and Well-being: The NINDS Social Determinants of Health Framework

A National Institute of Neurological Disorders and Stroke working group developed the Determinants of Inequities in Neurological Disease, Health, and Well-being framework. Our goal was to guide and inspire a new generation of neurologic research that pushes the field to design and test new approaches in pursuit of health equity, population health, and social justice. We seek to expand the lens of those looking to reduce or eliminate racial, socioeconomic status, and other inequities in neurologic disease, health, and well-being to improve our collective ability to create research, programs, and policies that lead to larger, more impactful, and more sustainable change in neurologic disease patterns. In this context, we outline a framework that includes and highlights "upstream" factors in the hopes of enhancing the focus of research, programmatic, and policy efforts to reduce and eliminate inequities in neurologic health and well-being. We explicitly discuss racism and other structural factors to clarify that social determinants are not natural and unchangeable. Populations with a disproportionate burden of neurologic disease are not inherently deficient, despite what some approaches to framing health inequities imply. The framework is presented linearly, but the pathways linking the determinants of neurologic disease, health, and well-being are far more complex than those demonstrated by the arrows included in the figure. The framework highlights the different levels and scale of causation, including the structural and intermediary social determinants and their impact on neurologic health. We offer this framework to refine efforts to contextualize the interpretation of neurologic research findings and suggest new avenues for their application. We illustrate how behavioral and biological factors occur in a social and economic context, factors that have been understudied as points of intervention to reduce inequities in neurologic disease. Considering social and structural determinants of health provides promising new opportunities to achieve neurologic health equity, reach social justice, and improve our science. Extending our work in this fashion is not simply about health equity or social justice but to fundamentally improve the quality of neurologic research by enhancing underlying theory and improving study design and implementation.

Stroke Experiences and Unmet Needs of Individuals of African Descent Living in High-Income Economy Countries: a Qualitative Meta-Synthesis

BACKGROUND

Stroke service disparities experienced by individuals of African descent highlight the need to optimize services. While qualitative studies have explored participants' unique experiences and service needs, a comprehensive synthesis is lacking. To address current knowledge gaps, this review aimed to synthesize existing literature on the experiences of individuals of African descent impacted by a stroke living in high-income economy countries in terms of stroke prevention, management, and care.

METHODS

A qualitative meta-synthesis incorporating a meta-study approach was conducted to obtain comprehensive and interpretive insights on the study topic. Four databases were searched to identify qualitative English-language studies published in the year 2022 or earlier on the experiences of adults of African descent who were at risk or impacted by a stroke and living in high-income economy countries. Study methods, theory, and data were analyzed using descriptive and interpretive analyses.

RESULTS

Thirty-seven studies met our inclusion criteria, including 29 journal articles and 8 dissertations. Multiple authors reported recruitment as a key challenge in study conduct. Multiple existing theories and frameworks of health behaviours, beliefs, self-efficacy, race, and family structure informed research positionality, questions, and analysis across studies. Participant experiences were categorized as (1) engagement in stroke prevention activities and responses to stroke symptoms, (2) self-management and self-identity after stroke, and (3) stroke care experiences.

CONCLUSIONS

This study synthesizes the experiences and needs of individuals of African descent impacted by stroke. Findings can help tailor stroke interventions across the stroke care continuum, as they suggest the need for intersectional and culturally humble care approaches.

The Racial Disparity among the clinical outcomes post Stroke and its intervention outcomes: A Systematic Review and Meta-analysis

BACKGROUND

The Racial disparity between the clinical outcomes post stroke have not been well studied, with limited literature available.

OBJECTIVE

We conducted a meta-analysis to evaluate the post-stroke outcomes among the White and Black race of patients METHODS: We systematically searched all electronic databases from inception until 1st March 2023. The primary endpoint was post stroke in-hospital mortality, and all-cause mortality. Secondary endpoints were post-stroke intervention in-hospital mortality, intracerebral hemorrhage, and all-cause mortality (ACM) RESULT: 1250397 patients were included in the analysis, with 1018892 (81.48%) patients of the White race and 231505 (18.51%) patients in the Black race. The mean age of the patients in each group was (73.55 vs 66.28). The most common comorbidity among White and Black patients was HTN (73.92% vs 81.00%), and DM (29.37% vs 43.36%). The odds of in hospital mortality post stroke (OR, 1.45(95%CI:1.35-1.55), P<0.001), and all-cause mortality (OR, 1.40(95%CI:1.28-1.54), P<0.001) were significantly higher among White patients compared with Black patients. Among patients with post stroke intervention the odds of in-hospital mortality (OR, 1.29 (95% CI: 1.05-1.59, P=0.02), and intracerebral hemorrhage (ICH) (OR, 1.15, (95%CI:1.06-1.26), P<0.01) were significantly higher among White patients compared with Black patients post intervention. However, all-cause mortality (OR,1.21(95%CI: 0.87-1.68, P=0.25) was comparable between both groups.

CONCLUSION

Our study is the most comprehensive and first meta-analysis with the largest sample size thus far, highlighting that White patients are at increased risk of mortality and post intervention intracerebral hemorrhage compared with Black patients.

Outcome Prediction in Cerebral Venous Thrombosis: The IN-REvASC Score

BACKGROUND

We identified risk factors, derived and validated a prognostic score for poor neurological outcome and death for use in cerebral venous thrombosis (CVT).

METHODS

We performed an international multicenter retrospective study including consecutive patients with CVT from January 2015 to December 2020. Demographic, clinical, and radiographic characteristics were collected. Univariable and multivariable logistic regressions were conducted to determine risk factors for poor outcome, mRS 3-6. A prognostic score was derived and validated.

RESULTS

A total of 1,025 patients were analyzed with median 375 days (interquartile range [IQR], 180 to 747) of follow-up. The median age was 44 (IQR, 32 to 58) and 62.7% were female. Multivariable analysis revealed the following factors were associated with poor outcome at 90- day follow-up: active cancer (odds ratio [OR], 11.20; 95% confidence interval [CI], 4.62 to 27.14; P<0.001), age (OR, 1.02 per year; 95% CI, 1.00 to 1.04; P=0.039), Black race (OR, 2.17; 95% CI, 1.10 to 4.27; P=0.025), encephalopathy or coma on presentation (OR, 2.71; 95% CI, 1.39 to 5.30; P=0.004), decreased hemoglobin (OR, 1.16 per g/dL; 95% CI, 1.03 to 1.31; P=0.014), higher NIHSS on presentation (OR, 1.07 per point; 95% CI, 1.02 to 1.11; P=0.002), and substance use (OR, 2.34; 95% CI, 1.16 to 4.71; P=0.017). The derived IN-REvASC score outperformed ISCVT-RS for the prediction of poor outcome at 90-day follow-up (area under the curve [AUC], 0.84 [95% CI, 0.79 to 0.87] vs. AUC, 0.71 [95% CI, 0.66 to 0.76], χ2 P<0.001) and mortality (AUC, 0.84 [95% CI, 0.78 to 0.90] vs. AUC, 0.72 [95% CI, 0.66 to 0.79], χ2 P=0.03).

CONCLUSIONS

Seven factors were associated with poor neurological outcome following CVT. The INREvASC score increased prognostic accuracy compared to ISCVT-RS. Determining patients at highest risk of poor outcome in CVT could help in clinical decision making and identify patients for targeted therapy in future clinical trials.

Gait evaluation in stroke hemiplegic patients using short physical performance battery

OBJECTIVES

Falls can occur daily in stroke patients and appropriate independence assessments for fall prevention are required. Although previous studies evaluated the short physical performance battery (SPPB) in stroke patients, the relationship between SPPB and fall prediction and walking independence remains unclear. Therefore, we aimed to verify whether SPPB is a predictor of walking independence.

MATERIALS AND METHODS

The present study included 105 hemiplegic stroke patients who were admitted to the rehabilitation ward and gave consent to participate. Cross-sectional physical function and functional independence measure cognitive (FIM-C) evaluation were conducted in hemiplegic stroke patients. Logistic regression analysis using the increasing variable method (likelihood ratio) was performed to extract factors for walking independence. Cutoff values were calculated for the extracted items using the receiver operating-characteristic (ROC) curve.

RESULTS

Among 86 participants included in the final analysis, 36 were independent walkers and 50 were dependent walkers. In the logistic regression analysis, SPPB and FIM-C were extracted as factors for walking independence. The cutoff value was 7 [area under the curve (AUC), 0.94; sensitivity, 0.83; specificity, 0.73)] for SPPB and 32 (AUC, 0.83; sensitivity, 0.69; specificity, 0.57) for FIM-C in ROC analysis CONCLUSIONS: SPPB and FIM-C were extracted as factors for walking independence. Although SPPB alone cannot determine independent walking, combined assessment of SPPB with cognitive function may enable more accurate determination of walking independence.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Importance

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.

Objective

To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities.

Design, Setting, and Participants

This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022.

Main Outcomes and Measures

Hospitals' likelihood of adopting stroke care certification.

Results

A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51).

Conclusions and Relevance

In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years

BACKGROUND

There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata.

METHODS

Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income.

RESULTS

The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups.

CONCLUSIONS

Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.

[Racial inequalities in access to rehabilitation after a stroke: study of the Brazilian population]

This article aims to verify the association between race/skin color and access to post-stroke rehabilitation services. It is a cross-sectional population-based study including 966 post-stroke adults (≥18 years) that responded to the National Health Survey (PNS). The outcome, access to rehabilitation, and exposure (race/skin color) were collected in a self-reported manner. Socio-demographic variables, clinical history, healthcare plan and post-stroke limitation were considered for the adjustment. Poisson regression with robust variance estimation was used to estimate the association in the crude and adjusted analyses. Based on the sample, 51.8% are self-declared black and 61.4% require rehabilitation, with only 20% having access to the rehabilitation service. Difficulty in accessing rehabilitation was reported by 57.5% of other self-declared races, 43% blacks, and 35.4% whites. In the adjusted analysis, 4% of self-declared black (PR 1.04, CI95%1.00-1.08) and 17% of self-declared yellow and indigenous (PR 1.17, IC95%1.13-1.20) have less access to rehabilitation than their white peers. In Brazil, self-declared black and yellow and indigenous people have worst access to post-stroke rehabilitation in comparison with self-declared white people, highlighting racial inequities in rehabilitation in stroke survivors.

Racial Variation in the Association Between Domains of Depressive Symptomatology and Functional Recovery in Stroke Survivors

OBJECTIVE

The purpose of the study was to investigate the relationships between various domains of depressive symptomatology and functional recovery in Black and White stroke survivors.

METHODS

Black (n = 181) and White (n = 797) stroke survivors from the Stroke Recovery in Underserved Population database were included. Four domains of depressive symptomatology (depressed affect, positive affect, somatic symptoms, interpersonal difficulties) were measured by the Center for Epidemiologic Studies Depression Scale at discharge; functional recovery was measured by the Functional Independence Measure at discharge and 3-month follow-up. Multivariable linear regression analyses examined the relation between race and functional recovery, and the association between depressive symptomatology and functional recovery by race.

RESULTS

Three-month functional recovery was greater among White stroke survivors than Black survivors. Affective symptoms of depression predicted poorer functional recovery of White survivors; whereas somatic symptoms predicted poorer functional recovery of Black survivors.

CONCLUSIONS

Domains of depressive symptomatology were differentially associated with poorer functional recovery in Black and White stroke survivors. Psychosocial interventions aimed at alleviating depressive symptomatology have the potential to improve functional recovery in Black and White stroke survivors and should be addressed in planning rehabilitation post-stroke.

Crafting Community-Based Participatory Research Stroke Interventions

Stroke exerts a tremendous burden on individuals, families, communities, and health systems globally. Even more troublesome are the striking disparities faced across diverse populations. These disparities are further exacerbated by the COVID-19 pandemic. Despite efforts to advance stroke research, substantial gaps remain in understanding factors that contribute to stroke disparities, including the Social Determinants of Health. Strategically designed studies and tailored interventions are needed to bridge the inequities high-risk populations face and to meet their specific needs. Community-based participatory research offers an approach to equitably partner with community members to understand and work collaboratively to address community-specific health priorities. In this focused update, we highlight the main processes of community-based participatory research studies and share exemplars from our team's work in stroke research and from the literature. As we continue to face an increasing prevalence of stroke, compounded by the COVID-19 pandemic and ongoing implications of the Social Determinants of Health, partnering with communities to address community-driven health priorities can inform interventions targeted to overcome the disparities faced by certain populations.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity

Importance

Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes.

Objective

To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke.

Design, Setting, and Participants

This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022.

Exposures

Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other.

Main Outcomes and Measures

Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke.

Results

Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke.

Conclusions and Relevance

In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.

'Timing it Right': needs of African American adults with stroke and their caregivers across the care continuum

Objective: African Americans are disproportionately affected by stroke in the United States (US). The purpose of this study is to explore experiences, wants, and needs of African Americans with stroke and their family caregivers residing in the stroke belt across the care continuum using the 'Timing It Right' (TIR) framework as a conceptual guide.Design: We conducted a series of focus groups among 20 African Americans living with stroke and 19 family caregivers. Focus groups were audio-recorded and transcribed verbatim. For this secondary analysis, we coded qualitative data using the TIR framework.Results: Participants in this sample identified pre-stroke needs in addition to the TIR phases that span across the care continuum and into community living. We identified four important contextual factors and real-world conditions that operate in the background and influence the post-stroke needs of this specific population across the TIR framework: (1) religion, faith, and church, (2) healthcare delivery, (3) community, and (4) sentinel events.Conclusions: We propose a TIR model that expands upon the original TIR framework which includes factors important for consideration when developing and delivering community-based interventions among African Americans with stroke and family caregivers in the southeastern US.

Feasibility of deploying peer coaches to mentor frontline home health aides and promote mobility among individuals recovering from a stroke: pilot test of a randomized controlled trial

BACKGROUND

Each year, approximately 100,000 individuals receive home health services after a stroke. Evidence has shown the benefits of home-based stroke rehabilitation, but little is known about resource-efficient ways to enhance its effectiveness, nor has anyone explored the value of leveraging low-cost home health aides (HHAs) to reinforce repetitive task training, a key component of home-based rehabilitation. We developed and piloted a Stroke Homehealth Aide Recovery Program (SHARP) that deployed specially trained HHAs as "peer coaches" to mentor frontline aides and help individuals recovering from stroke increase their mobility through greater adherence to repetitive exercise regimens. We assessed the feasibility of SHARP and its readiness for a full-scale randomized controlled trial (RCT). Specifically, we examined (1) the practicability of recruitment and randomization procedures, (2) program acceptability, (3) intervention fidelity, and (4) the performance of outcome measures.

METHODS

This was a feasibility study including a pilot RCT. Target enrollment was 60 individuals receiving post-stroke home health services, who were randomized to SHARP + usual home care or usual care only. The protocol specified a 30-day intervention with four planned in-home coach visits, including one joint coach/physical therapist visit. The primary participant outcome was 60-day change in mobility, using the performance-based Timed Up and Go and 4-Meter Walk Gait Speed tests. Interviews with participants, coaches, physical therapists, and frontline aides provided acceptability data. Enrollment figures, visit tracking reports, and audio recordings provided intervention fidelity data. Mixed methods included thematic analysis of qualitative data and quantitative analysis of structured data to examine the intervention feasibility and performance of outcome measures.

RESULTS

Achieving the 60-participant enrollment target required modifying participant eligibility criteria to accommodate a decline in the receipt of HHA services among individuals receiving home care after a stroke. This modification entailed intervention redesign. Acceptability was high among coaches and participants but lower among therapists and frontline aides. Intervention fidelity was mixed: 87% of intervention participants received all four planned coach visits; however, no joint coach/therapist visits occurred. Sixty-day follow-up retention was 78%. However, baseline and follow-up performance-based primary outcome mobility assessments could be completed for only 55% of participants.

CONCLUSIONS

The trial was not feasible in its current form. Before progressing to a definitive trial, significant program redesign would be required to address issues affecting enrollment, coach/HHA/therapist coordination, and implementation of performance-based outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04840407 . Retrospectively registered on 9 April 2021.

Black Patients with Ischemic Stroke and Hyperglycemia have Worse outcome than Whites if given Intensive Glucose Control

BACKGROUND

Hyperglycemia is common after acute ischemic stroke and is associated with worse outcome, but intensive glucose control has not improved outcome. There is also a racial disparity in outcome after stroke, with Black patients more likely to have functional impairment than whites. We aimed to evaluate if there were racial differences in outcomes in acute ischemic stroke patients treated with intensive glucose control.

METHODS

We performed a post-hoc analysis of the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial to determine if Black patients had worse functional outcome than whites and if standard versus intensive glucose control modified that association. We included non-Hispanic white and Black patients. The primary outcome was excellent functional outcome (90-day modified Rankin Score of 0-1). To account for patient clustering by study site, we fit mixed-effects logistic regression models to our outcome and tested the interaction of treatment and race.

RESULTS

We included 895 patients, of which 304 (34%) were Black and 591 (66%) were white. The rate of excellent outcome was 31.6% in Black patients versus 41.0% in white patients (p=0.006). After adjusting for potential confounders, the odds ratio for excellent outcome in Black patients was 0.54 (95% CI 0.38-0.77). The interaction term between treatment and race was significant (p=0.067). In the intensive treatment arm, Black patients had a predicted probability of excellent outcome of 26.4% (20.1-32.8) versus 42.7% (37.6-47.9) for white patients (p<0.001), while in the standard treatment arm the difference was not significant.

CONCLUSIONS

Black patients with acute ischemic stroke and hyperglycemia had worse functional outcome at 90 days than white patients, particularly if given intensive glucose control. These findings are from a post-hoc analysis and may be confounded, thus warrant additional study.

Factors associated with balance impairments amongst stroke survivors in northern Benin: A cross-sectional study

Background

Balance impairment is the predominant risk factor for falls in stroke survivors. A fear of falling after stroke can contribute to sedentary lifestyles, increased disability and risk of recurrence, leading to poor quality of life.

Objective

To determine the frequency and factors associated with balance impairments amongst stroke survivors at the University Hospital of Parakou.

Method

This cross-sectional study included adult stroke survivors. Stroke survivors after discharge were enrolled at the University Hospital of Parakou between 01 January 2020 and 30 September 2020. Balance impairments were measured by using the Berg Balance Scale (BBS), the Timed Up and Go (TUG) and the Get Up and Go (GUG) tests.

Results

A total of 54 stroke survivors were included, with a mean age of 58.37 ± 12.42 years and a male predominance of 68.52%. The mean BBS score was 36.87 ± 14.34 with a minimum and a maximum of 10 and 56, respectively. Thirteen (24.07%) had balance impairments (BBS score ≤ 20), 34 (62.96%) had a TUG score ≥ 14 s (abnormal), 9 (16.67%) presented a moderate risk of falling and 6 (11.11%) presented high risk of fall with the GUG test. Post-stroke duration (odds ratio [OR] = 0.04; 95% CI: 0.04–0.30; p < 0.01), severity of disability (OR = 8.33; 95% CI: 1.03–67.14; p = 0.03) and the number of physiotherapy sessions (OR = 0.18; 95% CI: 0.03–0.93; p = 0.02) were significantly associated with balance impairments.

Conclusion

Our results showed that almost one quarter of stroke survivors after discharge at the University Hospital of Parakou had balance impairments. Post-stroke duration, severity of disability and the number of physiotherapy sessions were significantly associated with balance impairments.

Clinical implications

[AQ1] Balance should be regularly assessed in people post-stroke. Further studies should document the content of rehabilitation and any rehabilitative efforts to improve balance in people post-stroke in Benin.

Racial and Socioeconomic Disparities in the Use and Outcomes of Endovascular Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Racial and socioeconomic disparities in the incidence, treatment, and outcomes of acute ischemic stroke exist and have been described. We aimed to characterize disparities in the use of endovascular thrombectomy in a nationally representative analysis.

MATERIALS AND METHODS

Discharge data from the Nationwide Inpatient Sample between 2006 and 2016 were queried using validated International Classification of Disease codes. Patients admitted to US hospitals with acute ischemic stroke were included and stratified on the basis of race, income, and primary payer. Trends in endovascular thrombectomy use, good outcome (discharge to home/acute rehabilitation), and poor outcome (discharge to skilled nursing facility, hospice, in-hospital mortality) were studied using univariate and multivariable analyses.

RESULTS

In this analysis of 1,322,162 patients, endovascular thrombectomy use increased from 53/111,829 (0.05%) to 3054/146,650 (2.08%) between 2006 and 2016, respectively. Less increase was observed in black patients from 4/12,733 (0.03%) to 401/23,836 (1.68%) and those in the lowest income quartile from 10/819 (0.03%) to 819/44,984 (1.49%). Greater increase was observed in the highest income quartile from 18/22,138 (0.08%) to 669/27,991 (2.39%). Black race predicted less endovascular thrombectomy use (OR = 0.79; 95% CI, 0.72-0.86). The highest income group predicted endovascular thrombectomy use (OR = 1.24; 95% CI, 1.13-1.36) as did private insurance (OR = 1.30; 95% CI, 1.23-1.38). High income predicted good outcome (OR = 1.10; 95% CI. 1.06-1.14), as did private insurance (OR = 1.36; 95% CI, 1.31-1.39). Black race predicted poor outcome (OR = 1.33; 95% CI, 1.30-1.36). All results were statistically significant (P < .01).

CONCLUSIONS

Despite a widespread increase in endovascular thrombectomy use, black and low-income patients may be less likely to receive endovascular thrombectomy. Future effort should attempt to better understand the causes of these disparities and develop strategies to ensure equitable access to potentially life-saving treatment.

Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk factor: Protocol of a RCT

BACKGROUND

Geographical and racial disparities in stroke outcomes are especially prominent in the Southeastern United States, which represents a region more heavily burdened with stroke compared to the rest of the country. While stroke is eminently preventable, particularly via blood pressure control, fewer than one third of patients with a stroke have their blood pressure controlled ≥ 75% of the time, and low consistency of blood pressure control is linked to higher stroke risk.

OBJECTIVE

To demonstrate that a mHealth technology-centered, integrated approach can effectively improve sustained blood pressure control among stroke patients (half of whom will be Black).

DESIGN

The Program to Avoid Cerebrovascular Events through Systematic Electronic Tracking and Tailoring of an Eminent Risk-factor is a prospective randomized controlled trial, which will include a cohort of 200 patients with a stroke, encountered at two major safety net health care systems in South Carolina. The intervention comprises utilization of a Vaica electronic pill tray & blue-toothed UA-767Plus BT blood pressure device and a dedicated app installed on patients' smart phones for automatic relay of data to a central server. Providers will follow care protocols based on expert consensus practice guidelines to address optimal blood pressure management.

STUDY OUTCOMES

Primary outcome is systolic blood pressure at 12-months, which is the major modifiable step to stroke event rate reduction. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life.

DISCUSSION

We anticipate that a successful intervention will serve as a scalable model of effective chronic blood pressure management after stroke, to bridge racial and geographic disparities in stroke outcomes in the United States.

TRIAL REGISTRATION

ClinicalTrials.gov - NCT03401489.

Race/Ethnic and Stroke Subtype Differences in Poststroke Functional Recovery After Acute Rehabilitation

OBJECTIVE

Significant racial/ethnic disparities in poststroke function exist, but whether these disparities vary by stroke subtype is unknown. Study goals were to (1) determine if racial/ethnic disparities in the recovery of poststroke function varied by stroke subtype and (2) identify confounding factors associated with these racial/ethnic disparities.

DESIGN

Secondary analysis of the 1-year Stroke Recovery in Underserved Populations Cohort Study.

SETTING

Eleven inpatient rehabilitation facilities (IRFs) across the United States.

PARTICIPANTS

A total of 1066 patients (n=868 with ischemic stroke and n=198 with hemorrhagic stroke, N=1066) who self-identified as White (n=813), Black (n=183), or Hispanic (n=70).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM scores at IRF admission, discharge, 3 months, and 12 months were modeled using multivariable mixed effects longitudinal regression.

RESULTS

Compared with White patients, Black (-6.1 and -4.6) and Hispanic (-10.1 and -9.9) patients had significantly lower FIM scores at 3 and 12 months, respectively. A significant (P<.01) 3-way interaction (race/ethnic*subtype*time) indicated that disparities varied by stroke subtype. The stroke subtype differences were most prominent for Black-White disparities because disparities in hemorrhagic stroke were present at IRF admission (vs 3 months for ischemic stroke). Additionally, at 12 months, the magnitude of Black-White disparities was over 3 times larger for hemorrhagic stroke (-10.4) than ischemic stroke (-3.1). Age primarily influenced Black-White disparities (especially for hemorrhagic stroke), but factors that influenced Hispanic-White disparities were not identified. Sensitivity analyses showed that there were stroke subtype differences in racial/ethnic disparities for cognitive (but not motor) function, and results were robust to adjustments for missing data because of attrition.

CONCLUSIONS

There are significant differences between stroke subtypes in the timing and magnitude of Black-White disparities in poststroke function. Age was a major confounding factor for Black-White disparities (particularly for hemorrhagic stroke). Overall, Hispanic patients had the lowest levels of poststroke function, and more work is needed to identify significant factors that influence Hispanic-White disparities.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

A SCANO Nomogram for Individualized Prediction of the Probability of 1-Year Unfavorable Outcomes in Chinese Acute Ischemic Stroke Patients

Background and Purpose: Accurate prediction of functional outcomes after stroke would provide evidence for reasonable poststroke management. This study aimed to develop and validate a nomogram for individualized prediction of 1-year unfavorable outcomes in Chinese acute ischemic stroke (AIS) patients.

Methods: We gathered AIS patients at the National Advanced Stroke Center of Nanjing First Hospital (China) between August 2014 and May 2017 within 12 h of symptom onset. The outcome measure was 1-year unfavorable outcomes (modified Rankin Scale 3–6). The patients were randomly stratified into the training (66.7%) and testing (33.3%) sets. With the training data, pre-established predictors were entered into a logistic regression model to generate the nomogram. Predictive performance of the nomogram model was evaluated in the testing data by calculating the area under the receiver operating characteristic curve (AUC-ROC), Brier score, and a calibration plot.

Results: A total of 807 patients were included into this study, and 262 (32.5%) of them had unfavorable outcomes. Systolic blood pressure, Creatinine, Age, National Institutes of Health Stroke Scale (NIHSS) score on admission, and fasting blood glucose were significantly associated with unfavorable outcomes and entered into the SCANO nomogram. The AUC-ROC of the SCANO nomogram in the testing set was 0.781 (Brier score: 0.166; calibration slope: 0.936; calibration intercept: 0.060).

Conclusions: The SCANO nomogram is developed and validated in Chinese AIS patients to firstly predict 1-year unfavorable outcomes, which is simple and convenient for the management of stroke patients.

Disability in Community-Dwelling Older Adults: Exploring the Role of Stroke and Dementia

Objectives: We sought to determine the relative contributions of stroke, dementia, and their combination to disability and racial differences in disability among community-dwelling older adults. Methods: We performed a cross-sectional study of 6848 community-dwelling older adults. We evaluated the associations of stroke, dementia, and their combination with activities of daily living (ADL) limitations (range 0-7). We then explored the impact of stroke and dementia on race differences in ADL limitations using Poisson regression after accounting for sociodemographics and comorbidities. Results: After full adjustment, ADL limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 (95% CI 0.29-0.35) ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination -1.48% (95%CI -2.21% to -0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability.

Exploring Factors Contributing to Race Differences in Poststroke Disability

Background and Purpose- Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods- A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009-2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0-7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results- There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7-2.2]; P=0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2-2.4]; P=0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0-3.2] in blacks versus 1.4 [1.0-1.8] in whites, mean difference, 1.2 [0.5-1.9], P<0.001) and immediately poststroke (2.6 [2.0-3.3] in blacks versus 1.7 [1.2-2.1] in whites, mean difference, 1.0 [0.2-1.7], P<0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions- Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.

Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study

Background

Therapy is key to effective stroke care, but many patients receive little.

Objectives

To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.

Design

Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.

Setting

Stroke services in England, Wales and Northern Ireland.

Participants

A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.

Results

Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.

Limitations

Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.

Conclusions

Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.

Divergent poststroke outcomes for black patients: Lower mortality, but greater disability

OBJECTIVE

To explore racial differences in disability at the time of first postdischarge disability assessment.

METHODS

This was a retrospective cohort study of all Medicare fee-for-service beneficiaries hospitalized with primary ischemic stroke (ICD-9,433.x1, 434.x1, 436) or intracerebral hemorrhage (431) diagnosed from 2011 to 2014. Racial differences in poststroke disability were measured in the initial postacute care setting (inpatient rehabilitation facility, skilled nursing facility, or home health) with the Pseudo-Functional Independence Measure. Given that assignment into postacute care setting may be nonrandom, patient location during the first year after stroke admission was explored.

RESULTS

A total of 390,251 functional outcome assessments (white = 339,253, 87% vs black = 50,998, 13%) were included in the primary analysis. At the initial functional assessment, black patients with stroke had greater disability than white patients with stroke across all 3 postacute care settings. The difference between white and black patients with stroke was largest in skilled nursing facilities (black patients 1.8 points lower than white patients, 11% lower) compared to the other 2 settings. Conversely, 30-day mortality was greater in white patients with stroke compared to black patients with stroke (18.4% vs 12.6% [p < 0.001]) and a 3 percentage point difference in mortality persisted at 1 year. Black patients with stroke were more likely to be in each postacute care setting at 30 days, but only very small differences existed at 1 year.

CONCLUSIONS

Black patients with stroke have 30% lower 30-day mortality than white patients with stroke, but greater short-term disability. The reasons for this disconnect are uncertain, but the pattern of reduced mortality coupled with increased disability suggests that racial differences in care preferences may play a role.

Racial and ethnic differences in post-stroke subjective cognitive decline exist

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.

Black/Hispanic Disparities in a Vulnerable Post-Stroke Home Care Population

Significant racial and ethnic disparities in stroke risk factors, occurrence, and outcomes persist in the USA. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP > 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients' SBP-the leading modifiable cause of stroke-and physical function-a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy, and current alcohol drinking (vs. abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.

Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty

OBJECTIVES

We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients.

METHODS

We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models.

RESULTS

The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001).

CONCLUSIONS

Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools

Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.

Commentary: Addressing Racial Disparities in Stroke: The Wide Spectrum Investigation of Stroke Outcome Disparities on Multiple Levels (WISSDOM)

Racial-ethnic disparities in stroke recovery are well-established in the United States but the underlying causes are not well-understood. The typical assumption that racial-ethnic disparities in stroke recovery are explained by health care access inequities may be simplistic as access to stroke-related rehabilitation, for example, does not adequately explain the observed disparities. To approach the problem in a more comprehensive fashion, the Wide Spectrum Investigation of Stroke Outcome Disparities on Multiple Levels (WISSDOM) was developed to bring together scientists from Regenerative Medicine, Neurology, Rehabilitation, and Nursing to examine disparities in stroke "recovery." As a result, three related projects (basic science, clinical science and population science) were designed utilizing animal modeling, mapping of brain connections, and community-based interventions. In this article we describe: 1) the goals and objectives of the individual projects; and 2) how these projects could provide critical evidence to explain why racial-ethnic minorities traditionally experience recovery trajectories that are worse than Whites.

No Racial Difference in Rehabilitation Therapy Across All Post-Acute Care Settings in the Year Following a Stroke

BACKGROUND AND PURPOSE

Black stroke survivors experience greater poststroke disability than whites. Differences in post-acute rehabilitation may contribute to this disparity. Therefore, we estimated racial differences in rehabilitation therapy utilization, intensity, and the number of post-acute care settings in the first year after a stroke.

METHODS

We used national Medicare data to study 186 168 elderly black and white patients hospitalized with a primary diagnosis of stroke in 2011. We tabulated the proportion of stroke survivors receiving physical, occupational, and speech and language therapy in each post-acute care setting (inpatient rehabilitation facility, skilled nursing facility, and home health agency), minutes of therapy, and number of transitions between settings. We then used generalized linear models to determine whether racial differences in minutes of physical therapy were influenced by demographics, comorbidities, thrombolysis, and markers of stroke severity.

RESULTS

Black stroke patients were more likely to receive each type of therapy than white stroke patients. Compared with white stroke patients, black stroke patients received more minutes of physical therapy (897.8 versus 743.4; P<0.01), occupational therapy (752.7 versus 648.9; P<0.01), and speech and language therapy (865.7 versus 658.1; P<0.01). There were no clinically significant differences in physical therapy minutes after adjustment. Blacks had more transitions (median, 3; interquartile range, 1-5) than whites (median, 2; interquartile range, 1-5; P<0.01).

CONCLUSIONS

There are no clinically significant racial differences in rehabilitation therapy utilization or intensity after accounting for patient characteristics. It is unlikely that differences in rehabilitation utilization or intensity are important contributors to racial disparities in poststroke disability.

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

Longstanding disparities have been reported in stroke-related outcomes with blacks experiencing more post-stroke disabilities. Little is known about long-term disability outcomes among older stroke survivors. This study was a retrospective analysis of data from the 2015 National Health Interview Survey (NHIS). A group of 655 stroke survivors (541 white and 114 black) age 65 and older were asked to rate their ability to complete 10 functional tasks without special equipment. Univariate comparisons were completed using t-tests and chi-square statistics for racial comparisons of disability reports. Multinomial logistic regression was used to determine odds of reporting disability after controlling for relevant covariates. The mean age of the sample was 76.6 years. After controlling for relevant covariates, white stroke survivors were less likely to report the following tasks being "very difficult/can't do at all" without using special equipment compared to blacks: reach overhead (OR = 0.39, 95% CI 0.23⁻0.65; p = 0.000) and grasp small objects (OR = 0.42, 95% CI 0.25⁻0.73; p = 0.002). Both black and white older stroke survivors experience significant post-stroke disability across a range of functional tasks. Slightly greater long term post-stroke disability appears to exist among older blacks.

African American Stroke Survivors: More Caregiving Time, but Less Caregiving Burden

BACKGROUND

Blacks have higher stroke incidence and experience greater poststroke disability than whites. To optimize care for stroke survivors, it is important to understand the amount of care that they receive and the implications for stroke caregivers.

METHODS AND RESULTS

Data from 2 nationally representative, population-based studies, the NHATS (National Health and Aging Trends Study) linked to the NSOC (National Study of Caregiving), were used to identify elderly stroke survivors and their caregivers. We compared hours of care received and unmet activity need among the 581 white and 225 black stroke survivors. We then performed racial comparisons of positive and negative aspects of caregiving reported by caregivers of black and white stroke survivors. Black stroke survivors were more likely than white stroke survivors to have a caregiver (62.5% versus 49.7%; P<0.01) and received on average more hours of help per week (31.7 versus 20.5; P<0.01). There was little racial difference in unmet need for assistance. Caregivers of black stroke survivors reported more positive aspects of caregiving than caregivers of white stroke survivors (6.8 versus 6.0; P<0.01). There was no racial difference in negative aspects of caregiving, depression, or anxiety.

CONCLUSIONS

Black stroke survivors received an average of ≈11 more hours of care than white stroke survivors without substantial differences in unmet need. Despite providing more hours of care, caregivers of black stroke were more positive about their caregiver role than caregivers of white stroke survivors.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

DISCUSSION

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

Medicare claims indicators of healthcare utilization differences after hospitalization for ischemic stroke: Race, gender, and caregiving effects

Background Differences in healthcare utilization after stroke may partly explain race or gender differences in stroke outcomes and identify factors that might reduce post-acute stroke care costs. Aim To examine systematic differences in Medicare claims for healthcare utilization after hospitalization for ischemic stroke in a US population-based sample. Methods Claims were examined over a six-month period after hospitalization for 279 ischemic stroke survivors 65 years or older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Statistical analyses examined differences in post-acute healthcare utilization, adjusted for pre-stroke utilization, as a function of race (African-American vs. White), gender, age, stroke belt residence, income, Medicaid dual-eligibility, Charlson comorbidity index, and whether the person lived with an available caregiver. Results After adjusting for covariates, women were more likely than men to receive home health care and to use emergency department services during the post-acute care period. These effects were maintained even after further adjustment for acute stroke severity. African-Americans had more home health care visits than Whites among patients who received some home health care. Having a co-residing caregiver was associated with reduced acute hospitalization length of stay and fewer post-acute emergency department and primary care physician visits. Conclusions Underutilization of healthcare after stroke does not appear to explain poorer long-term stroke outcomes for women and African-Americans in this epidemiologically-derived sample. Caregiver availability may contribute to reduced formal care and cost during the post-acute period.

Living in Latvia after stroke: the association between functional, social and personal factors and the level of self-perceived disability-a cross-sectional study

OBJECTIVE

To investigate how functional, social and personal factors are associated with self-perceived level of disability in the chronic phase of stroke in a Latvian stroke population. The consequences of stroke can vary greatly and often leads to long-term disability that, according to the WHO definitions, depends on the interaction between the person and his/her context.

DESIGN

Cross-sectional study with retrospective data gathering.

SETTING

Community-dwelling persons who received specialised in-patient rehabilitation after stroke in Latvia.

PARTICIPANTS

Of 600 persons after stroke who were identified through hospital register and selected for the study, 255 were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The medical information and discharge data of the Functional Independence Measure (FIM) was extracted from medical records. Participants filled out a questionnaire on sociodemographic information and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), either in Latvian or Russian, depending on their wish when contacted for their oral agreement to participate. Stepwise multiple regression analysis was conducted to find a model that best explains the variance in WHODAS 2.0 scores.

RESULTS

The models explained 23-43.5% of variance in outcomes. The best explained WHODAS 2.0 domains were 'mobility' and 'self-care'. The significant factors were level of independence in 'self-care', 'locomotion' and 'communication' according to FIM, as well as working status, time since rehabilitation, age, gender, living alone or in family and preferred language.

CONCLUSIONS

Functional, social and personal factors are of similar importance when explaining self-perceived disability in the chronic phase of stroke. Some, but not all, of the factors are modifiable by the healthcare system. Therefore, a complex approach and involvement of medical, social and political systems is needed.

The need to modify physical activity messages to better speak to older African American women: a pilot study

BACKGROUND

Combating the physical inactivity crisis and improving health and quality of life is a challenge and a public health priority, especially in underserved populations. A key role of public health consists of informing, educating, and empowering individuals and communities about health issues. Researchers have found that mass communication messages often have limited effectiveness in reaching and impacting the health of underserved populations. The present pilot study was designed to explore perceptions of older African American women (AAW) in response to widely disseminated public information pertaining to physical activity (PA) and aging.

METHODS

A total of 10 older AAW aged 60 years and over participated in this study. Participants were evenly assigned in one of the 2 focus groups (i.e. active, n = 5; and inactive, n = 5) based on their PA level. The focus group approach was employed to gather information about widely available public information materials related to PA that target the adult and older adult population. The three guides used were: (1) Exercise and Physical Activity: Your Everyday Guide; (2) The Physical Activity Guidelines for Older Adults; and (3) Be Active Your Way: A Guide for Adults. NVIVO 10 software was used to help in the qualitative data analysis. Descriptive thematic analysis was employed in identifying, analyzing and reporting patterns/themes within the data.

RESULTS

Older AAW in the present study identified some shortcomings in current public health materials. Participants from both focus groups raised concerns regarding language and the types of activities used as examples in the materials. After analysis, two themes emerged: "We may have trouble in reading it" and "It does not reflect us". Participants' evaluation was found to be similar between the active and inactive focus groups.

CONCLUSIONS

Older AAW's perceptions of the materials suggest that materials intended to educate and motivate the general public towards PA need to be modified to better speak to older African American women, especially to those who are sedentary and have difficulty in building PA into their daily lives.

Towards an Understanding of Racial Differences in Post-stroke Disability

Due to the aging of the baby boomer generation, the number of stroke survivors is expected to increase from 7 million to over 10 million in 2030. Stroke survivorship will be particularly important for African Americans who have a higher incidence of strokes compared to non-Hispanics whites and greater post stroke disability. Current evidence suggests that the most prominent racial differences in post-stroke disability emerge in the post-stroke period. Further work, with a focus on modifiable factors, is needed to understand which factors in the post-stroke period lead to racial differences in post-stroke disability.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Racial and Ethnic Differences in Mental Distress among Stroke Survivors

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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