Health Care Disparities in Stroke Rehabilitation.

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Racial and Ethnic Disparities in the Medical Management of Poststroke Complications Among Patients With Acute Stroke.

BACKGROUND: To inform clinical practice, we sought to identify racial and ethnic differences in the medical management of common poststroke complications. METHODS AND RESULTS: A cohort of acutely hospitalized, first-time non-Hispanic White (NHW), non-Hispanic Black, and Hispanic patients with stroke was identified from electronic medical records of 51 large health care organizations (January 1, 2003 to December 5, 2022). Matched propensity scores were used to account for baseline differences. Primary outcomes included receipt of medication(s) associated with the management of the following poststroke complications: arousal/fatigue, spasticity, mood, sleep, neurogenic bladder, neurogenic bowel, and seizure. Differences were measured at 14, 90, and 365 days. Subgroup analyses included differences restricted to patients with ischemic stroke, younger age (<65 years), and stratified by decade (2003-2012 and 2013-2022). Before matching, the final cohort consisted of 348 286 patients with first-time stroke. Matching resulted in 63 722 non-Hispanic Black-NHW pairs and 24 009 Hispanic-NHW pairs. Non-Hispanic Black (versus NHW) patients were significantly less likely to be treated for all poststroke complications, with differences largest for arousal/fatigue (relative risk (RR), 0.58 [95% CI, 0.54-0.62]), spasticity (RR, 0.64 [95% CI, 0.0.62-0.67]), and mood disorders (RR, 0.72 [95% CI, 0.70-0.74]) at 14 days. Hispanic-NHW differences were similar, albeit with smaller magnitudes, with the largest differences present for spasticity (RR, 0.67 [95% CI, 0.63-0.72]), arousal/fatigue (RR, 0.77 [95% CI, 0.70-0.85]), and mood disorders (RR, 0.79 [95% CI, 0.77-0.82]). Subgroup analyses revealed similar patterns for ischemic stroke and patients aged <65 years. Disparities for the current decade remained significant but with smaller magnitudes compared with the prior decade. CONCLUSIONS: There are significant racial and ethnic disparities in the treatment of poststroke complications. The differences were greatest at 14 days, outlining the importance of early identification and management.

Emulating 3 Clinical Trials That Compare Stroke Rehabilitation at Inpatient Rehabilitation Facilities With Skilled Nursing Facilities.

OBJECTIVE: To inform the design of a potential future randomized controlled trial (RCT), we emulated 3 trials where patient-level outcomes were compared after stroke rehabilitation at inpatient rehabilitation facilities (IRFs) with skilled nursing facilities (SNFs). DESIGN: Trials were emulated using a 1:1 matched propensity score analysis. The 3 trials differed because facilities from rehabilitation networks with different case volumes were compared. Rehabilitation network case volumes were based on the number of patients with stroke that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium and large case volumes (ie, ≥5 patients), and trial 3 included 19,161 patients from networks with large case volumes (ie, ≥10 patients). The E values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results. SETTING: A national sample of IRFs and SNFs from across the United States. PARTICIPANTS: Fee-for-service Medicare patients with acute stroke who received IRF or SNF based rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One-year successful community discharge (home for >30 consecutive days) and all-cause mortality. RESULTS: Overall, 29,500, 15,156, and 7450 patients were matched for trials 1, 2, and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21 (95% CI, 0.20-0.22), 0.17 (95% CI, 0.16-0.19), and 0.12 (95% CI, 0.10-0.14) in trials 1, 2, and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were -0.11 (95% CI, -0.12 to -0.11), -0.11 (95% CI, -0.12 to -0.09), and -0.08 (95% CI, -0.10 to -0.06). The E values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6-2.0 would nullify differences in successful community discharge. CONCLUSIONS: IRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.

Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities.

In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.

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.

Rs10230207 genotype confers changes in HDAC9 and TWIST1, but not FERD3L in lymphoblasts from patients with intracranial aneurysm.

Intracranial aneurysms (IA) are weakened outpouchings of the arterial wall in the cerebrovasculature. Rupture of an IA often leads to devastating consequences. The early identification of IA patients is crucial for management of their condition. A genetic variant at rs10230207, located nearby the HDAC9, TWIST1, and FERD3L genes, is associated with IA. HDAC9 is a class IIa histone deacetylase that mediates vascular smooth muscle cell dysfunction. TWIST1 is a mechanosensitive transcription factor and its expression is reduced in unstable carotid atherosclerotic plaques. In this study, the expression of the HDAC9, TWIST1, and FERD3L genes was characterized and associated with the presence of the rs10230207 genetic variant. Allelic discrimination and gene expression analysis were performed using lymphoblasts from 85 population controls and 109 IA patients. Subjects that were heterozygous (GT) within rs10230207 were 4.32 times more likely to have an IA than those that were homozygous for the reference allele (GG; 95%CI 1.23 to 14.16). Subjects that were homozygous (TT) were 8.27 times more likely to have an IA than those that were GG (95%CI 2.45 to 27.85). While the presence of the risk allele was not associated with changes in FERD3L gene expression, the risk allele was associated with increased HDAC9 and decrease in TWIST1 mRNA expression. The significant inverse correlation between HDAC9 and TWIST1 gene expression suggests that changes in the expression of both of genes may contribute to the formation of IAs.

Pain research from 1975 to 2007: a categorical and bibliometric meta-trend analysis of every Research Paper published in the journal, Pain.

In an attempt to characterize the nature of pain research, every one of the 4525 Research Papers published in the journal, Pain, from its inception until the end of 2007, was examined by a single individual using a consistent set of criteria, and was coded for its essential features in four domains: the purpose of the study (e.g., characterization of a pain syndrome, evaluation of the role of a molecule), the subjects of the study (patients, human "normals", animals), the pain states characterized or induced (clinical pain and experimental stimuli), and the dependent measures examined (e.g., behaviors, questionnaires, neural firing). For papers involving pain patients, the clinical conditions under study were coded as well. These categorical data were combined with bibliometric data obtained from citation databases. Together, the data allow an examination of 32-year trends in pain research, and comprise a data compendium fully searchable or sortable by any interested individual.