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

Misuse of multinomial logistic regression in stroke related health research: A systematic review of methodology

Multinomial logistic regression (MLR) is often used to model the association between a nominal outcome variable and one or more covariates. The results of MLR are interpreted as relative risk ratios (RRR) and warrant a more coherent interpretation than ordinary logistic regression. Some authors compare the results of MLR to ordinal logistic regression (OLR), irrespective of the fact that these estimate different quantities. We aim to investigate the time trends in the use and misuse of MLR in studies including stroke patients, specifically the extent to which (1) the results are denoted as anything other than RRR, (2) comparisons are made of results with results of OLR and (3) results have been interpreted coherently. Secondarily, we examine the use of model validation techniques in studies with predictive aims. We searched EMBASE and PubMed for articles using MLR on populations of stroke patients. Identified studies were screened, and information pertaining to our aims was extracted. A total of 285 articles were identified through a systematic literature search, and 68 of these were included in the review. Of these, 60 articles (88%) did not denote exponentiated coefficients of MLR as relative risk ratios but rather some other measure. Additionally, 63 articles (93%) interpreted the results of MLR in a non-coherent manner. Two articles attempted to compare MLR results with those of OLR. Nine studies attempted to use MLR for predictive means, and three used relevant validation techniques. From these findings, it is clear that the interpretation of MLR is often suboptimal.

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.

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.