Association Between Stroke-related Hospital Discharge Status and Socio-Demographic Characteristic in Tennesse

To the School of Graduate Studies and Research:

I am submitting herewith a thesis written by Edward M. Davis Jr. entitled: "ASSOCIATION BETWEEN STROKE-RELATED HOSPITAL DISCHARGE STATUS, SOCIO-DEMOGRAPHIC CHARACTERISTICS, INSURANCE STATUS AND URBAN-RURAL RESIDENCE IN TENNESSEE." I have examined the final copy of this thesis for form and content and recommend that it be accepted in partial fulfillment of the requirements for the degree of Master of Science in Public Health in the Division of Public Health Practice.

Director, MSPH Program

We have read the thesis and recommend its acceptance:

Chair

Accepted for the Graduate School

^QJU.c jLj. ]nr>c L py><_

Dean, School of Graduate Studies and Research

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.


ASSOCIATION BETWEEN STROKE-RELATED HOSPITAL DISCHARGE STATUS, SOCIO-DEMOGRAPHIC CHARACTERISTICS, INSURANCE STATUS AND URBAN-

RURAL RESIDENCE IN TENNESSEE

A Thesis

Presented for the

Masters of Science and Public Health Degree

Meharry Medical College

Edward Mitchell Davis Jr.

May 2010


UMI Number: EP31636

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INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted.

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Copyright © 2010 by Edward M. Davis Jr. All rights Resenyed

ii


DEDICATION

This thesis is dedicated to my sisters, Erica Megan Davis and

Michelle Nichole Brady-Davis.

iii


ACKNOWLEDGEMENTS

I would like to thank God for giving me the strength and focus to complete this

thesis project. I would like to thank my thesis committee: Dr. Green Ekadi, Mr. Paul

Henkel and Dr. Chau-Kuang Chen, for helping me mold this project into its present form.

Finally, I would like to thank my family for their constant encouragement and support,

thank you for providing me with the opportunities to attain my dreams.


ABSTRACT

Background: In the United States, more than 795,000 Americans suffer from a new or

recurring stroke. The southeastern region of the United Stated, known as the "stroke

belt", has a disproportionate rate of stroke cases compared to other areas in the United

States.

Problem: Tennessee ranks fifth in the nation in stroke prevalence. Research shows that

African-Americans (AA) have an increased risk of stroke incidence and severity

compared to Caucasian Americans (CA).

Objective: This study investigates what factors help to predict where stroke patients will

be discharged to when they complete stroke related in-hospital stays,

Methods: Patient discharge status, the dependent variable, classified as discharge to:

home, assisted living facility (ALF) or inpatient rehabilitation facility (IRF). Independent

discharge variables included; age, race, sex, insurance, and urban-rural residence.

Multinomial logistic regression was used for analysis.

Results: Determinants of ALF discharge versus home were: stroke type (hemorrhagic

[OR 6.38], ischemic [OR 4.38]) and public insurance [OR 1.20]. Determinants of IRF

discharge versus home were: stroke type (hemorrhagic [OR 24.71], ischemic [15.85])

and urban residence [OR 1.18]. AAs and Women £ aged 70 years were more likely to be

discharged home versus any other discharge destination; possibly due insurance,

income, and family support. Stroke-related discharge incorporates associations that are

important to the public health impact of stroke in Tennessee.

v


TABLE. OF CONTENTS

CHAPTER PAGE

I. INTRODUCTION 1

II. REVIEW OF SELECTED LITERATURE 6

III. METHODOLOGY 32

IV. RESULTS 41

V. DISCUSSION 48

REFERENCES 57

APPENDICES 63

VITA 67

vi


LIST OF ABBREVIATIONS

Intracerebral Ischemic Stroke ICH

Subarachnoid Hemorrhage SAH

Transient Ischemic Attack TIA

African-American AA

Caucasian-American CA

Hospital Discharge Data System HDDS

Assisted Living Facility ALF

Inpatient Rehabilitation Facility IRF

vii


INTRODUCTION

Background

Each year more than 795,000 Americans suffer from some type of new or

recurring stroke. In the United States, the number of deaths due to stroke averages

more than 143,000 each year (Lloyd-Jones, 2009). Stroke is currently the third leading

cause of death in the United States, third only to heart disease and cancer

("FASTSTATS - Deaths and Mortality", 2009). About 25 percent of those who suffer

from strokes die at the time of the event, or soon after, and 15-30 percent remain

permanently or severely disabled.

More than one million Americans and their families live with the disabling

effects of stroke. Over the years, researchers have observed trends in prevalence and

incidence in stroke cases among certain races and age groups in the United

States.("The Paul Coverdell National Acute Stroke Registry," 2009) The most significant

of these trends are observed among African-Americans 35 years and older. In addition

to these trends observed in age and race, there are also geographical trends observed

in certain areas of the United States where there are increased prevalence and

incidence of stroke victims.

1


Nature of the Problem

There is a severe disparity of stroke-related hospital admissions and

discharges among African-Americans due to greater severity of cerebrovascular disease

type. The southeastern region of the United States has had the highest incidence and

mortality of stroke (Alberts, 1995). Several states in this region are collectively known as

the "stroke belt". This region of the United States consists of an eleven state regions

including Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North

Carolina, South Carolina, Tennessee and Virginia. These states have been classified as

the stroke belt due to the significantly greater incidence of stroke in these states

compared to the United States collectively. Tennessee has the fifth highest prevalence

of stroke in the nation ("Prevalence of Stroke - United States 2005," 2007). In 2005, the

deaths due to stroke in Tennessee versus the United States population were 63.0 per

100,000 of population and 46.6 per 100,000, respectively (Vital Health Statistics, 2008).

The CDC Atlas of Stroke Mortality reports higher deaths due to stroke

among males than females, however females experience a greater number of lifetime

events and hospitalizations (Casper, 2003). However there is great degree of

controversy regarding sex differences in stroke incidence and severity (Petrea, 2009).

Similar to national data and statistics, stroke is the third leading cause of death in

Tennessee, accounting for 7% of the deaths in 2004.("Tennessee Heart Disease and

Stroke Prevention Program: Statistics and Reports," 2006). For African-Americans and

Caucasian-Americans in Tennessee, the age-adjusted rate of death due to stroke is

higher among Caucasian-Americans. However, in Tennessee, this requires more

research due to lack of data reported for locations with low populations, especially

among minority populations.

2


Significance of Study

Incidence and prevalence of stroke in Tennessee are among the highest

in the United States. In addition, in 2008, Tennessee was among the states in the South

that had the highest population living below the poverty line (DeNavas-Walt, Proctor, &

Smith, 2009). This is significant in terms of access to care, insurance coverage, and

incidence of illness. According to the demographic features of this regional population

and measure of overall disparity among the population at risk for cerebrovascular

populations, there is a correlation between risk and severity of disease that must be

researched further. With population characteristics such as these it is important to

better understand the association between these factors and severity of stroke to

determine the best care procedures. Stroke related hospital admission and discharge

are an important source of data to analyze in order to determine the threats and

characteristics which contribute most to the occurrence of stroke among different

demographics of Tennesseans.

This study will compare stroke incidence based on case severity with factors

such as urban-rural residence in Tennessee, socio-demographic characteristics,

insurance status, and patient status at discharge to better understand and address the

disparity of health care access and quality of care to rural and urban communities.

Previous studies, which focus on measuring stroke severity, have evaluated the impact

of stroke using differently methods of measurement. In this study however, severity is

determined based on the outcome of each individual stroke-related hospital discharge.

Where a patient was discharged to (level of care) will suggest how severe his or her

stroke event was. Each patient's severity of illness is attributed to each patient's

diagnosed condition, and is highly dependent on where the patient was discharged.

Post-discharge, each level of post-stroke care suggests an implied level of self-care. An

3


individual who is discharged to his or her home is able to complete all activities of daily

living or require assistance with which another member of the household can provide

assistance. A stroke-patient discharged to an inpatient rehabilitation hospital has little or

no ability to provide care for himself or herself. An intermediate care facility, which

provides assisted living care, allows some patient independence, and self-care.

In this study, the results will attempt to outline a pattern of stroke occurrence

based on stroke type, origin of admission (residence), and patient demographics.

Analyzing the factors that contribute to health status is important in investigating how

health related predictor variables contribute to understanding linkages among behavior,

lifestyle and population health.

Theoretical Framework for Study

The Population Health Model forms the theoretical framework for this study, it

has been in existence since the time of Hippocrates, and has been instrumental in

explaining causes of disease and providing health care ever since (Radzyminski, 2007).

The Population Health Model incorporates theories regarding two broad perspectives,

the understanding of macro-level trends in health status, and the evaluation of the

performance of the healthcare system (Singer & Ruff, 2001). These perspectives are

important because they target behavior and lifestyle, as they relate to the onset and

outcomes of disease. The Population Health Model is useful to frame this research

project because it considers relationships among an individual's biologic characteristics,

and their interactions with peer groups and families. In addition, the economic, cultural,

social, and physical environmental conditions at the local, national and global levels

(Fielding, Teutsch, & Breslow, 2010).

4


This study is modeled after the Population Health Model framework, because it

plans to determine a relationship between the predominant input variables of the Model

including: biologic, geographic, social economic status (SES) and socio-demographic

factors. The contextual trends associated with certain diseases are important to study

instead of simply the biologic trends of a disease. Supporters of the Population Health

Model have emphasized the importance of the Model addressing health disparities

because, "although human biology is relatively uniform across the species, thus lending

itself to the medical model, human behavior, culture, and social change are not,...good

health depends on much more than adequate diagnosis, treatment, and patient

knowledge of health care issues" (Radzyminski, 2007)

Objectives of Study

The objectives of this study are: (1) to evaluate the association between

Tennessee stroke-related hospital discharges and socio-demographic characteristics

such as age, sex and race, (2) to evaluate the association between stroke-related

hospital discharges and rural-urban residence, (3) to evaluate the association of stroke-

related hospital discharges with insurance status.

5


REVIEW OF SELECTED LITERATURE

Stroke Type and Severity Measures

Stroke, a disease that affects the blood vessels leading to and within the brain,

can manifest itself in three forms, two primary stroke forms, and a tertiary "stroke-like"

attack; hemorrhagic, ischemic, and transient ischemic attack, respectively. Each of

these stroke types will be identified further and in detail in this study. Transient ischemic

attack (TIA), or transient cerebral attack, is classified as a clinical syndrome caused by

inadequate cerebral or ocular blood supply due to arterial thrombosis or embolism (blood

clot) byway of arterial, cardiac, or hematological disease.(M. Correia, M. Silva, R.

Magalhaes, L. Guimaraes, & C. Silva, 2006)

The primary descriptive trait of a TIA is that it is usually resolved within 24 hours,

and is often characterized as a "warning stroke."("What you need to know about TIAs,"

2009) In terms of each of the three stroke types, a TIA is the least severe of

cerebrovascular attacks because there is no permanent injury to the brain and, as the

definition states, it resolves itself within 24 hours.fWhat you need to know about TIAs,"

2009) Ischemic attacks, however are a more severe manifestation of stroke in

comparison to TIAs, due to the fact that they are not resolved in short periods of time.

Ischemic strokes occur as a result of an obstruction within a blood vessel supplying

blood to the brain, either through cerebral thrombosis (blood clot) or cerebral embolism

(transport of blood clot)("Types of Stroke," 2009). The most severe manifestation of

6


cerebrovascular attack involves hemorrhage of vessels in the brain or in the vessels

leading to the brain. There are two types of cerebral hemorrhage that may occur;

subarachnoid or intracerebral cerebral hemorrhage (American Heart Association, 2009).

Primary intracerebral hemorrhage (PICH), also called simply intracerebral hemorrhage,

ranges from 78-88% of all hemorrhages of small vessels damages by chronic

hypertension or amyloid angiopathy (Paolucci, et at., 2003).

Cerebrovascular disease hemorrhage is estimated to affect an extensive

population worldwide each year. Most individuals affected by this form of stroke are

disabled or require rehabilitation services and in some cases die due to its effects on the

brain. In comparison to ischemic stroke, or cerebral infarction, there is a higher risk of

fatality due to hemorrhage stroke. However, in a study regarding the outcomes of

cerebrovascular disease cases, researchers found that stroke survivors diagnosed with

hemorrhagic stroke had better neurologic and functional progress than ischemic stroke

patients (Chae, Zorowitz, & Johnston, 1996). A similar study, which aimed at clarifying

the rehabilitation results between ischemic and hemorrhagic patients also found that

there was better functional recovery among intracerebral hemorrhage stroke patients, in

comparison to ischemic stroke patients. In fact, the in the matched comparison the

researchers also found that hemorrhagic patient also had better discharge status

following inpatient discharge as well (Paolucci, et al., 2003). The most significant factor

that was accounted for in the in the Paolucci study is stroke severity. Stroke severity is

considered the most powerful prognostic factor, and can describe the reason why many

patients who experience ischemic stroke, have worse outcomes that those who

experience hemorrhagic stroke.

The-level of stroke severity is a measure that is difficult to determine based on

the stroke diagnosis alone. This is supported by the fact that some hemorrhagic stroke

7


patients experience better outcomes that ischemic stroke patients. One would infer that

the exact opposite would be the case; however this is not accurate in all situations.

Many researchers have made use of stroke scales to determine severity of patient

strokes. Some of the most popular and widely used stroke scales to determine severity

or level of disability are, the Scandinavian Stroke Scale (SSS) (Anderson, Olsen,

Dehlendorff, & Kammersgaard, 2009), the NIH Health Stroke Scale (NIHHS) (Schlegel,

Tanne, Demchuk, Levine, & Kasner, 2004), the Barthel Index (Horner, Matcher, Divine,

& Feussner, 1991) and the All patient refined diagnosis related group (APR-DRG)

subclass severity of illness. While the APR-DRG subclass severity illness is a measure

related to all hospital related diagnoses and procedures, not just stroke, it is a good

measure for any procedure which takes place in a hospital setting. TIA will be classified

as a "warning stroke" and will be included in analysis in terms of the risk factors

contributing to its onset, however because it is the least severe, by definition resolving

itself in 24 hours and not indicative of an official stroke classification, it will be classified

as the least severe stroke type for this thesis project (Shen & Washington, 2007).

Hemorrhagic stroke types, including subarachnoid and intracerebral hemorrhage,

are the most severe stroke types in comparison to ischemic infarction. In a recent study

comparing the two cerebrovascular disease types, hemorrhagic has found to be most

severe and detrimental to patients. In this study the SSS stroke scale was used to

determine the effects of stroke on patients. Stroke scales differ based on the variables

used to measure level of severity; the SSS scale evaluates level of consciousness, eye

movement, power in arm, hand and leg orientation, aphasia and facial paresis.

Collectively these measures calculate an aggregate score which is given to each patient

upon evaluation to measure stroke severity. This is an important function of treatment

and care, because stroke case severity in many cases determines destination of

8


discharge among other things. In the study by Anderson et a, 2009, patients with

hemorrhagic stroke were found to be more severe when compared to ischemic infarct.

The SSS stroke scale is measured using a 0-58 point scale, 0 being the most severe

case. The mean SSS score of ischemic infarct and hemorrhagic stroke were 28.3 and

42.9 respectively (p<0.001). This supports that hemorrhagic stroke cases are

significantly more severe than ischemic attacks. The level of stroke severity directly

coincided with hemorrhagic stroke; in fact only 2% of hemorrhagic stroke had the lowest

severity while 30% had the highest severity (Anderson, Oisen, Dehlendorff, &

Kammersgaard, 2009).

In a similar study, the researchers reported that hemorrhagic stroke is directly

associated with higher mortality among these patients (Shen & Washington, 2007).

These results were also found in a study which measured rehabilitative recovery of

patients post-stroke. Stroke has debilitating effects on stroke patients based on severity

of each stroke case. Among patients who suffered from hemorrhagic stroke, there was

more significant functional impairment than among the ischemic infarct patients (Kelly, et

al., 2001). This study confirms the clinical validity that hemorrhagic strokes are

considered a more severe stroke type than ischemic stroke. Severity in most cases

increases based on the amount of relevant risk factors recorded for each patient. The

most significant risk factors observed are those that contributed most to severity of

hemorrhagic stroke were high alcohol intake and smoking (Anderson, Olsen,

Dehlendorff, & Kammersgaard, 2009). These results show that based on patient's

health behavior and practices, many people experience difference levels of stroke

events.

Another stroke scale used to measure severity and determine the rehabilitation

effects based on stroke diagnosis is the Barthel Index, which measures ability to

9


complete activities of daily living. The rehabilitation rate based on stroke type is a

measure which is important to severity and for determining the "best" discharge setting

for post-stroke patients. Using the Barthel Index as a measure of stroke severity, the

research hers found that the outcome determinants for rehabilitation included age and

onset-admission interval (OAI) which determines the patient's status at admission to the

treating hospital. Each of these factors contributes to the functional outcome for each

patient. To distinguish severity by stroke type, stroke cases we re grouped and matched

by diving cases into two stroke types: ischemic stroke and hemorrhagic stroke. By

matching the stroke types, a clear characterization of the role of each prognostic factor

on functional outcome of severity on rehabilitation of stroke patients was observed and

the role of the association of the prognostic factors which contribute to outcome in

analysis was minimized (Paolucci, et al., 2003). Using the Barthel Index, results of this

study showed that better functional recovery was observed among hemorrhagic stroke

patients in rehabilitation compared to ischemic patients. Hemorrhagic stroke patients

showed significant functional gains at a faster rate than ischemic patients. The results

among hemorrhagic patients' recovery is significant because using a severity measure

towards recovery, is useful to improving knowledge on rehabilitation among stroke

survivors.

A third example of a stroke scale used to determine stroke severity is the

National Institutes of Health Stroke Scale (NIHSS). The NIHSS is a scale which

measures neurological deficit and has been used as a predictive outcome measure for

stroke events (Lyden, et al., 1994). This scale considers several different stroke related

effects to determine severity and discharge outcome in its calculation. These effects

include level of consciousness, gaze, visual fields facial palsy, motor strength, ataxia,

sensation, language, dysarthia, and inattention, and have been found to be effective in

10


predicting hospital discharge disposition in prior studies (Schlegel, Tanne, Demchuk,

Levine, & Kasner, 2004).

Another method for determining case severity is through the "severity of illness",

subclass from the prospective payment system (PPS) diagnosis related groups (DRG)

developed by Yale University. The DRG system takes all possible diagnoses from the

ICD-9-CM system and classifies them into 25 major diagnostic categories by organ

system (Cleverley & Cameron, 2007). The DRG system is a classification system that

hospitals use to relate types of patient hospital treatments (i.e., its case mix) to the costs

incurred by the hospital. There are three different forms of DRG classes that hospitals

use to determine case mix: the basic DRG (used by the Centers for Medicare and

Medicaid Services (CMS) for hospital payment for Medicare beneficiaries), All Patient

DRGs (an expansion of the basic DRGs to be more representative of non-Medicare

populations) and All-Patient Refined DRG (only grouping which incorporates severity of

illness in patient classification) (3M Health Information Systems, 2003).

The APR-DRG was expanded with severity of illness and risk of mortality

because no other DRG classification system addresses these pertinent characteristics of

patient care. The APR-DRGs expand the basic DRG structure by adding four

subclasses to each DRG. The addition of the severity of illness is important to hospital

patient care, and has represented solid measures in determining hospital illness and

severity well in practice. In a study which tested the differences and accuracy of

inpatient severity of illness, code-based severity scales performed significantly better

than clinical measure to assess severity. Diagnosis codes indicating postoperative, life-

threatening conditions contribute to the superior predictive power of code-based

measures (Lezzoni, Ash, Shwartz, Landon, & Mackiernan, 1998). Odds ratios were

derived from the data in the previous study, and the results showed that code-based

11


measures performed statistically better. These results are highly significant in proving

the accuracy of the code-based severity measures, compared to other stroke scale

measures. Though the DRG related severity of illness is not explicitly stroke specific as

many of the other stroke scales, it is a reliant predictor of severity and is useful in

determining patient guidelines.

A final measure of stroke severity is the utilization of post-stroke rehabilitation

facilities such as nursing homes and rehabilitation inpatient hospitals. In 2001,

approximately half of all stroke survivors were discharged to an institutional setting (18%

inpatient rehabilitation, 30%skilled nursing facility) (Deutsch, et al., 2006) This statistics

suggest that a large percent of stroke surviving patients were not well enough to return

home. The major difference between these two rehabilitation destinations is the level

care offered to each patient, and can be considered a measure of stroke severity.

Experts recommend that the selection of rehabilitation care should be primarily based on

each patient's motor and cognitive functioning, physical activity, endurance, and social

support. There has been little research done to investigate the relationship between;

stroke type, severity and rehabilitation setting (Brown, et al., 1999), (Deuts.ch, et al.,

2006). Using post-stroke discharge setting as a severity measure outcome will

contribute evidence regarding this topic.

Hospital Discharge and Stroke Outcomes

Hospital discharge status is a measure that can be used in several ways to

determine the severity of an illness and the long term impact of a disease on a patient.

Stroke can be a devastating disease, depending on severity and stroke type. Many / .

stroke victims may be subject to weeks or months of rehabilitation services based on

discharge status. At discharge, hospitals determine discharge status based on ability to

12


function at the next level of care (Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004).

That may include home/self-care, intermediate/assisted living, or transfer to another

institution/hospital. Hospitalizations may be prolonged because of the need for

comprehensive assessment of physical, occupational, and speech therapists, as well as

approvals by patient's families, insurers, and rehabilitation sites before discharge

(Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004). Many variables can affect

patients discharge status, and each of these variables contributes to the final post-stroke

outcome and overall condition of each patient.

There is not a great deal of information describing the influence of discharge

functional status on the rehabilitation measures (Reistetter, et al., 2010), however they

have been a handful of studies which have attempted to determine the correlation

between the two. Stroke is a leading cause of disability among adults, (Rosamond, et

al., 2008), and is the most frequent impairment category as a result inpatient

rehabilitation (/\ data book: health-care spending and Medicare program, 2009). Due to

the level of impact that negative outcomes of inpatient stroke admissions can lead to,

hospitals attempt to create the most positive outcome for each patient, through effective

care, diagnosis and treatment and based on these outcomes determine discharge

setting. Stroke studies which classify the most favorable post-stroke discharge settings

are a topic which has met much a great deal of debate. Some researchers classify

discharge to home, or "community," as the'most favorable discharge status. Whereas

other studies however, define discharge to a rehabilitation facility as the most desirable

post-stroke discharge setting. In a study by Reistetter et al., discharge to community

was described "as a global goal for all patients and an important quality indicator for

program evaluation and accreditation reviews," suggesting that the most favorable

outcome of a stroke event at discharge is to home. The views of this author favor the

13


position that a non-rehabilitation setting is not the most favorable outcome of hospital

discharge. In this study the authors are considering the additional dangers that

accompany institutional care such as, infections, falls, and reconditioning which can

present even more negative effects on the patient.

Conversely in a similar study, with different views on the subject of post-stroke

patient discharge, researchers classify discharge to rehabilitation facility as the most

favorable discharge outcome following a stroke inpatient hospitalization rather than to

home or any other post-stroke setting for patients who need these services

(Ottenbacher, Campbell, Kuo, Deutsch, Ostir, & Granger, 2008). Levels of rehabilitative

care do depend heavily on insurance coverage and family instructions, however, the

when rehabilitative care is enabled positive long-term outcomes for the patient are likely

to follow.

Differences in discharge setting have been observed among stroke patients who

experience ischemic and hemorrhagic stroke measured by severity of stroke admission

and level of inpatient recovery. As mentioned earlier in this chapter, increasing level of

severity is associated with greater likelihood of discharge to rehabilitation or nursing

facilities (Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004). In a study which used

the Rochester Epidemiology Project to evaluate the use of nursing homes after stroke

and assess the dependence of discharge to nursing homes based on stroke type and

level of disability (severity), will be useful in showing trends of between discharge, stroke

type and severity. Among the study population of stroke cases based on level of

severity, the results were consistent with the notion that the less severe stroke cases

were not discharged to nursing homes, while more severe cases were. 59% percent of

severe stroke cases ended up in nursing home setting, compared to only 5% of less

severe cases discharged to nursing homes. Severity of stroke also had implication on

14


the amount of time that a patient spent in nursing home and assisted living care. In a

five year time span after initial event and entrance into the care of a nursing home, 21%

of severe stroke cases were still in nursing home care, compared to only 9% of minor

stroke cases (Brown, et al., 1999). Differences between stroke type, among

hemorrhagic stroke types, patients diagnosed with intracerebral hemorrhage were much

more likely to be in a nursing home, compared to patients diagnosed with subarachnoid

hemorrhage. Severity has a significant role in discharge status setting based on level on

independence. The care that patients receive in these facilities is intended to mimic

hospital care and improve or recondition activities of daily living. In the Brown et al,

study, the researchers found that increasing age and severity were directly related to

discharge and length of stay in nursing home settings. The occurrence of stroke among

elderly populations and severity of illness are major contributions to discharge setting.

Other associations that have been identified to contribute to discharge are race and

ethnicity.

A study which analyzed the post-acute hospital outcomes between racial and

ethnic groups highlighted stroke hospital discharge outcomes among African-Americans

and non-Hispanic Caucasian-Americans. The researchers hypothesized that the

functional status among non-Hispanic African-Americans will be higher (or have more

favorable outcomes), than other racial/ethnic groups. In addition to this, the study also

hypothesized that racial and ethnic differences would be observed based on discharge

setting, i.e., the patient is discharged to return home versus to a secondary care facility,

that ethnic groups with non-Hispanic Caucasian-Americans would be discharge home

more frequently than African-Americans. The independent variable listed in this study,

was race/ethnicity, while the dependent variables listed in this study included: functional

status, length of stay, efficiency and discharge status.

15


In this analysis discharge stats was designated as discharge to "home" and "not

to home", where "not to home" was included various secondary healthcare facilities.

Results of this study showed that there was a significant racial difference in the

percentage of non-Hispanic Caucasian-American and African-American patients

discharged home. Sixty-six percent of Non-Hispanic Caucasian-Americans were

discharged home while; Seventy-four percent of all African-American patients were

discharge home. Analysis showed that among non-Hispanic Caucasian-Americans who

receive rehabilitation after stroke, were older, less likely to have Medicaid, and less likely

to have had a hemorrhagic stroke (Ottenbacher, Campbell, Kuo, Deutsch, Ostir, &

Granger, 2008).

These characteristics are consistent with many of the high prevalence stroke

cases among African-Americans. In previous studies, African-Americans have

consistently experienced a higher degree of hemorrhagic stroke and were younger.

Discharge to home is usually viewed as a positive outcome, ana is considered an

indicator of quality care. However, in this study, the researchers suggest that patient

and family preferences play an important role in discharge planning and placement. To

support this assertion, in a study which analyzed African-American attitudes about long-

term care, African-Americans tend to view nursing homes negatively, and the percent of

persons from these the African-American community are low(Miller, McFall, & Campbell,

1994). The disparities among racial/ethnic groups are significant and in this example,

the researchers show how post stroke outcomes are also observed among minority

populations (Ottenbacher, et al., 2008).

Socioeconomic status (SES) and race are additional demographics that

contribute to observed disparities in outcome and discharge status. As stated in the

previous study, access to certain rehabilitation services due to SES are major

16


contributors to occurrence and ability to health and recover from cerebrovascular

disease events (Asylanyan, Weir, Lees, Reid, & Gordon, 2003). Differential access to

timely acute and post acute services play a major role in recovery after discharge due to

patient discharge status. Stroke patients who receive prompt stroke rehabilitation

services following stroke discharge have been associated with having better recovery of

physical function in the immediate and following years (Indredavik, Bakke, Slordahl,

Rokseth, & Haheim, 1999). In certain cases, the most favorable destination after

discharge is to a rehabilitation facility, based on the stroke severity. However, under

certain circumstances access to rehabilitation healthcare services is not as easily

accessible for patients with discharge statuses that require these services. The racial

differences in the process and outcomes of stroke rehabilitation after discharge are

addressed in a study which analyzed the racial differences in access to stroke

rehabilitation and degree of physical functional status. Results showed the post-stroke

environment affected racial/ethnic groups differently. On average, African-Americans

recovered physical function at a slower rate during the first year after stroke. This was

directly associated with the delay in access to inpatient rehabilitation services that

Africans Americans experienced. Income and socioeconomic status was evaluated as a

contributing factor worse outcome. Low-Income African-Americans experienced a

greater delay in functional recovery due to stroke incidence. The pace of recovery from

stroke is more likely inhibited by aspects such as poverty, absence of supportive social

services, such as in-home care, or rehabilitation services, at discharge. (Horner,

Bosworth, & Matcher, 2003) It is important to explore to the outcomes at discharge and

post-discharge status of patients and trends between stroke patients to improve the

services available to encourage the best possible outcomes for each patient.

17


The capacities to perform activities of daily living (ADL), activities which show

personal independence and self-care abilities) at discharge are one of the measures that

health care organizations use to determine effects of stroke events and future care. In

this study, the researchers analyze the differences in physical and functional

impairments related to outcome of ischemic stroke by race. The study population

included 146 patients with ischemic stroke: 41 (28%) African-American and 104 (74%)

Caucasian-American patients (one American Indian ischemic stroke patient was

excluded from analysis). From the breaking down of the patient population, there is a

significant difference amount of African-American ischemic stroke cases, which suggests

that African-Americans do not suffer from ischemic stroke as often as Caucasian-

Americans. In addition to this, the researchers also found that a history of transient

ischemic attack (TIA) among African-Americans was less prevalent, than Caucasian-

Americans, (p=0.055). These two observations are important in explaining the trend of

prevalence of hemorrhagic stroke among the African-American population. Additionally,

a greater amount of stroke admissions came from urban communities. Physical

impairments and negative outcomes due to ischemic stroke were profound among the

African-American population. The median level of physical impairment was significantly

greater among African-Americans, 30, 90, and 180 days after initial event. During

statistical analysis, the researchers found race to be an important independent prediction

of physical impairment, (p=0.045). Among African-Americans, physical impairment from

ischemic stroke was greater among African-Americans that in Caucasian-American.

However, in terms of functional ability as measured by activities of daily living,

Caucasian-Americans had a longer approximated recovery time those African-

Americans stroke patients. The rate of recovery based on activities of daily living among

Caucasian-Americans was 3-6 months after acute event. Rate of recovery and physical

18


and functional results of stroke differ between the races. There is no concrete evidence

as to solid reasoning as to why this has been observed, however, race has been

associated a contributing factor to outcome after ischemic stroke.

Caucasian-Americans are less likely than non-Caucasian-Americans to be

discharged to nursing homes. This me be due to their stroke-type was less severe or

they responded better to stroke treatment than other races/ethnicities. Individuals aged

65 years and greater, have a higher probability of discharge to a nursing facility

increased by 2.5. Patients may be less able to care for themselves and may be more

commonly require long-term placement and care. This is supported by the fact that 90%

of nursing facility residents is older than 65 years of age.

Racial/Ethnic Cerebrovascular Disease Trends

Continuing the discussion of cerebrovascular disease as it related the race and

ethnicity, there is a significant disparity among certain groups in the incidence and

prevalence of cerebrovascular disease that must be mentioned. The 30-day case

mortality rate for ICH cases is 40% to 50%, for each patient in which ICH occurs (Woo,

et al., 2002). Several studies have found that the ICH stroke type occurs most

prevalently among African-Americans and Caucasian-Americans. Studies have

suggested that Caucasian-Americans are more likely to develop occlusive disease if the

large extra cranial vessels (carotid, vertebral, basilar), while African-Americans, are

more likely to develop occlusions of the intracranial (especially intracerebral) blood

vessels(Klatsky, Armstrong, & Friedman, 1991).

This study uses a population of both African-American and Caucasian-Americans

who received health examinations from cerebrovascular disease hospitalizations.

Discharge diagnostic codes used in this study however were International Classification

19


of Disease Codes, Eighth edition. Cerebrovascular codes used for analysis were codes

430-438. These codes included hemorrhage subtypes, ischemic, and acute ill-defined

cerebrovascular disease. Following analysis, and categorization by race, African-

Americans, compromised 30.8% of the study population, and were overrepresented

among the hemorrhagic cerebrovascular disease cases (31 of 69, 44.9%) and slightly

underrepresented among the occlusive cerebrovascular disease cases (72 of 292,

24.7%). A consistent male versus female preponderance was found among both racial

groups favoring higher rates of cerebral thrombosis among makes. The age-adjusted

relative risk of hospitalization for hemorrhagic cerebrovascular disease, African-

American versus Caucasian-American, was 2.64, (95% CI 1.62-4.30). Among African-

Americans participating in this study, results were consistent suggesting that they had

significantly higher risk that Caucasian-Americans for subarachnoid and intracerebral

hemorrhage stroke types (Klatsky, et al., 1991).

In one study in particular, of a study population of 1,051 patients with ICH cases,

98% of these patients were either African-American or Caucasian-American. This study

demonstrates the significance of ICH cases among young and middle-aged African-

Americans. This disparity observed through the relative risk of ICH for African-Americans

versus Caucasian-Americans, which was 1.6 (95% CI, 1.4-1.8). Additionally, risk was

also observed as greater among Africans Americans aged 35-54 years of age (young

and middle-age). The age mean of age those diagnosed with ICH among both races

was 61.9 years of age versus 72.1 years of age. The authors of this research study

suggest that the findings of this study suggest that the higher rates of ICH in African-

American are likely attributable to the difference in prevalence and control of

hypertension, which besides the age of each patient, produces the greatest attributable

risk for ICH among this racial group. (Flaherty, et al., 2005) Hypertension is one of the

20


primary causes of many stroke types, and most significant the reason that stroke occurs

in African-Americans.

Another study analyzing the severity and long term effects of intracerebral

hemorrhage found that, primary intracerebral hemorrhage (PICH) is associated with

poorer outcomes than cerebral infraction, or ischemic stroke. Strokes which involve

complete hemorrhage of vessels can lead to mortality in many more situations than

other stroke cases. This has been determined by researchers who have observed

poorer outcomes among those who suffer from intracerebral hemorrhage. In a study

which matched intracerebral hemorrhage and ischemic attack, results showed that

greater neurological damage and mortality occurred among individuals who suffer from

intracerebral hemorrhage, than those suffering from ischemic stroke. (M Barber, 2004) In

a study reporting on the differences between the two hemorrhages formations, African-

Americans have a higher incidence of cerebral infraction, subarachnoid hemorrhage and

intracerebral hemorrhage (Gorelick, 1998). These rates are generally more

disproportionate for African-Americans at relatively younger ages (Broderick, 1992).

Neurological damage is one of the possible outcomes of cerebrovascular, disease, and

as described here was associated with PICH stroke types more than any other. In a

similar study however, the physical and functional impairments that can result from any

cerebrovascular stroke type can arise from ischemic stroke as well.

To further emphasize the disparity observed among cerebrovascular hemorrhage

cases in the African-American Population, a study was performed using the South

London Stroke Register, which included an area defined by census data in 2001, with

271, 817 participants. This was further broken down into, 63% Caucasian, 28% African

(9% Caribbean African, 15% African Undefined). In this study, both hemorrhagic

strokes, and primary intracerebral hemorrhage were analyzed to determine most

21


significant prevalence between racial groups. Among the study population there were

566 (395 PICH and 171 SAH) patients who were diagnosed with first-ever hemorrhagic

stroke. The results after analysis for greatest significance of hemorrhagic stroke, found

that 60% of Caucasian decent and 70% of African descent had a history of hypertension.

Additionally, hypertension was most prevalent among ethnic groups in patients younger

than 65 years of age 52% Caucasian, 74% African-Caribbean, 70% African-Undefined.

Between the hemorrhagic stroke types, African Caribbean's had almost twice the crude

incidence rate when compared to African-Undefined and Caucasians. However, overall,

all patients of African descent in the study had consistently higher risk of PICH when

compared to Caucasian-Americans. This was signified by the IRR for stroke types PICH

and SAH were 2.86 and 1.22, respectively. IRR was consistently higher for patients of

African descent among individuals 65 years of age or less. The other hemorrhagic

stroke subtype, subarachnoid hemorrhage (SAH), has been shown to be more frequent

among Caribbean Africans, than Caucasians or African-undefined in the London Stroke

Registry(Smeeton, et al., 2007). SAH is frequently associated with intracranial

aneurysm, and there is some evidence of a genetic link between intracranial aneurysm

and SAH (Markus & Alberts, 2005). These results support the assertion that.patients of

African descent are disproportionately more likely to experience hemorrhagic stroke type

hospitalizations (Smeeton, et al., 2007).

About 80% of strokes are caused by focal cerebral ischemia (ischemic stroke)

due to arterial occlusion, and the remaining 20% are caused by hemorrhages, (van der

Worp & van Gijn, 2007) Despite the statistic that a greater percentage of stroke cases

are less severe, ischemic stroke cases, the smaller more severe case ratio cannot be

neglected because these cases are effecting certain populations more than others, i.e.

22


hemorrhagic stroke cases among certain racial and ethnic groups. Differences have

been observed among certain ethic groups of the outcomes of stroke type.

Trends among Stroke and Insurance Status

Health insurance is seen as an important means of offering financial protection

for healthcare services sought by the general population. Insurance coverage play a

major role in stokes care and rehabilitation care. The accessibility and availability of

rehabilitative care with some of the most sever stroke cases is the driving factor which

supports full, partial, or no recovery from stroke patient. Another important relationship

involving patient insurance is post-stroke patient discharge. "Hospitalizations may be

prolonged because of the need for comprehensive assessments by physical,

occupational, and speech therapist as well as approvals insurers, families, and

rehabilitation sites" (Schlegel, Tanne, Demchuk, Levine, & Kasner, 2004).

Lack of health insurance among Americans has become increasingly problematic

for both families and individuals. The rates of uninsured among nonelderly Americans

have grown rapidly. The Henry Kaiser Foundations points out that, "not having health

insurance makes a difference in people's access to needed medical care and their

financial security. The barriers the uninsured face in getting the care that they need

means they are less likely to receive preventive care, are more likely to be hospitalized

for conditions that could have been prevented, and are more likely to die in the hospital

than those with insurance." This observation is highly noteworthy when stroke-related

events occur. 17% of the nonelderly population is uninsured, and 42% of this group is

classified as having no access to preventive care (The Henry Kaiser Family Foundation,

2008). Health insurance coverage serves as a mode of patients to readily receive.

healthcare treatment however, due to the financial and social barriers associated with

23


attaining insurance coverage, many people are left without adequate coverage. Prior

studies have shown the unfavorable impact on health status that lack of health coverage

can create (Institute of Medicine , 2002). In fact, evidence has directly implicated

uninsured patients as being less likely to receive the required care they need and

experience poorer outcomes than other patients as a result no insurance coverage

(Shen & Washington, 2007). In 2002, the cost of treating stroke patients was estimated

at 56.8 billion, of which 35 billion was directly associated with medical treatment (Shen &

Washington, 2007). As can be expected, due to these annual charges, hospital inpatient

stays due to stroke can be extremely expensive and without insurance cause many

patients to not qualify to receive necessary rehabilitative services post-stroke. Not only

does insurance affect post-stroke discharge status, but it also affects care prior to stroke

leading up to a stroke event. Regular healthcare services are an important part of living

healthy and monitor the stroke risk factors to minimize the odds of stroke.

However, stroke related insurance disparities are not only observed among the

uninsured. In a study which analyzed the occurrence of stroke among the African-

American population, results found that since 1990, the gap for excess incidence of

stroke among African-American men and women who are Medicare beneficiaries, when

compared to Caucasian-Americans of the same payer classification. (Gorelick P. B.,

1998) This data finds that stroke does not only affect those patients who are uninsured;

instead it affects a multitude of people, with different levels of access to healthcare

services.

A study that evaluated the outcomes of stroke events by stroke attempted to

determine the behavior of insurance coverage on stroke outcomes. The results of this

study showed that uninsured patients experienced the most negative effects due to

stroke in comparison to their insured counterparts. The researchers measured stroke

24


outcomes based on neurologic impairments and mortality. This was an adequate

measure because of the effects that stroke has on the brain. The study states that,

"differences in both age and severity levels seem to be an indication of inadequate

access to preventive services" (Shen & Washington, 2007). To support this statement,

in a report by the Kaiser Family Foundation, almost half of America's population (42%)

had no access to preventive care (The Henry Kaiser Family Foundation, 2008).

Deeper into the insurance disparity among stroke patients, variations are observed

between insurance companies. The Shen and Washington results found that privately

insured patients are more likely to undergo primary or secondary prevention in the

absence of acute stroke symptoms. This directly supports the fact that insured

individuals are subject to have better outcomes post-stroke due to stroke. Additionally,

these findings also suggest that differences in services are present between public,

private and uninsured patients. Results have shown that uninsured patient is subject to

the most negative outcomes, however in some cases, "disparities...between patients

with Medicaid and privately insured patients existed in some cases..." (Shen &

Washington, 2007). The differences between insured individuals are an interesting

statistic to note. Among insured patients who received a carotid endarterectomy, a

procedure performed on stroke patients to enable oxygen to get to the brain" privately

insured patients received the treatment more often than public insurance (Medicaid)

patients (Shen & Washington, 2007).

The relationship between patients post-stroke discharge setting and insurance is

coverage is varies based on several factors that can affect the recovery of the patient.

In 2001, approximately half of all stroke survivors discharged from acute care hospitals

were admitted to institutional post acute care setting, including 18% admitted to inpatient

rehabilitation facilities and 30% admitted to skilled nursing facilities (Deutsch, et al.,

25


2006). When patients are not able to return home after discharge, alternative care must

be sought for patients. In this study by Deutsch et al, the researchers compare the

outcomes and reimbursements for care provided in institutional rehabilitation facilities

(IRF), and skilled nursing facilities (SNF). Differences in care between these two care

facilities are, IRF's provide intensive rehabilitation treatment to patient during a short,

whereas the sub acute rehabilitation provides various levels of treatments typically over

a longer period of time. These differences in care are indicative of the level of severity,

and patient discharge status. The authors reported that patients treated in IRFs had

better outcomes, with patients showing higher level of motor function, or discharge at

conclusion of rehabilitation was better when compared to SNFs. Patients motor function

was an important factor of rehabilitation however, intensive IRF service did not result in

better outcomes for patient with minimal motor disabilities. Nearly all patient with

minimal motor disabilities returned to the community setting, regardless of the

rehabilitation setting (IRF or SNF). Additionally, significant differences were found

between Medicare reimbursements between both post stroke rehab settings showed.

Among IRFs the payment per patient was almost double that of SNFs, with $12,320 and

$6,215 respectively. Despite the observation that IRF payments were higher than SNF

payments, the median IRF length of stay was significantly shorter than the median

length of stay in SNFs (Deutsch, et al., 2006). This observation suggests that despite

the higher expense of care in IRFs patients care was better due to the more favorable

results in IRFs than SNFs.

Several studies have identified hypertension as a primary risk factor for cause of

stroke. Hypertension has been identified as a significant contributor to stroke especially

among African-Americans. Additionally, previous stroke studies have shown that

hypertension is a significant risk factor for intracerebral hemorrhage and subarachnoid

26


hemorrhage (Woo, et al., 2002), (Kissela, et al., 2002). Due to this observation that

hypertension piays a significant role in the occurrence of stroke, then it can be

concluded that control of this risk factor will reduce the occurrence of stroke. In a study

by Woo et al, the researchers attempt to observe the effects of treated and untreated

hypertension on hemorrhagic stroke. The underpinnings of this analysis deal primarily

with insurance coverage availability, and how access to quality healthcare to treat risk

factors of stroke are integral to controlling and greatly reducing the risk of stroke. One

would presume that grater control of blood pressure would lead to a greater reduction in

risk of stroke (Woo, et al., 2004). In this study 549 hemorrhagic stroke cases were

identified, 322 SAH and 227 ICH.

The major disparities identified among hemorrhagic stroke patients (either SAH

or ICH) was, 71% had hypertension. Furthermore, 23% of African-Americans in this

population suffered from untreated hypertension. When comparing these results of non-

African-Americans included in these study, African-Americans tended to have higher

rates of hypertension and untreated hypertension than non-African-Americans. In this

study, treatment of hypertension meant that subjects were on medication to lower blood

pressure. Also, when considering only subjects with hypertension, 33% were African-

Americans not being treated this condition, compared with 26% of non-African-

Americans not being treated for hypertension. This study exerts results that show that

untreated hypertension is associated with both hemorrhagic stroke types, in addition to

lower education level and previous ischemic stroke. Untreated hypertension has several

implications to patient socio-demographics. Insurance coverage is determinant of

several factors but many of them have to deal with socioeconomic status, and health

history. In this study, researchers observed that insurance status among self-pay and

Medicaid patients, untreated hypertension than treated hypertension patients. These

27


results equate to access to healthcare for patients without insurance (self-pay) or on

Medicaid were more likely to be in the untreated hypertension group rather than the

Medicare or private insurance patients (Woo, et al., 2004). These results are highly

significant is connecting the risk factors of which cause to the actual onset of stroke

cases. Hypertension, is still reported to be a major contribute to stroke, however as

seen from the study describe previously, stroke is much less prevalent among patient

whose hypertension is treated.

In another study which highlighted the association between stroke and insurance

status, researchers observed that primary intracerebral hemorrhage was associated with

higher mortality; however greater neurological damage among this population was not

an observational trait across health insurance status. However, among the uninsured

population in this study, those who suffered from hemorrhagic stroke symptoms were

found to have greater chances of mortality.

Urban-Rural Residence and Stroke Incidence Trends

Epidemiological studies have researched the racial/ethnic geographical trends of

stroke incidence. These studies have investigated the relationship between the types

and occurrences of stroke that plague individuals in with varying results. Research has

found that varying trends between urban and rural residences are observed among

stroke patients and cases. The urban-rural composition of the United States favors the

non-Hispanic, Caucasian-American population. The total urban population in the United

States consists of 60.6% non-Hispanic, Caucasian-Americans. Conversely, the total

rural population in the United Sates consists is 83.5% non-Hispanic, Caucasian-

American. These percentage of non-Hispanic Caucasian-Americans, heavily favors in

rural populations, which suggests that many of the stroke trends observed among this

28


racial/ethnic group should be favored in these regions of the United States. African-

Americans compose a considerably less amount of the total population in both urban

and rural settings in the United States. In urban populations, Among African-Americans

comprise 14.2% of this area. Whereas in rural communities, African-Americans

comprise only 6.4% of this total population (U.S. Census Bureau, 2007). The members

of the population in the urban and rural comminutes in the United States are important to

the results observed among cerebrovascular disease patients in these areas.

In a study performed in a rural community in Georgia, similar to the differences in

the racial/ethnic make-up the United States, this rural community consisted primarily of

Caucasian-Americans (60%). This results of this studied did not have an urban

community to compare its results to, however, despite this the trends observed in the

rural community, mimics the population trends that are observed among Africans

Americans in other populations. The African-Americans in this rural Georgia community,

suffered from higher stroke incidence rates in comparison to Caucasian-Americans in

this same community. African-American women have nearly 3-times the rate of stroke

as Caucasian-Americans. The incidence of stroke increased with age; however the

increase was not as significant as the rate of stroke observed among the African-

American population (Heyman, et al., 1971). This study was one of the first of many

race/ethnic comparisons on the basis of stroke incidence. The fact that it focuses on

rural residence makes it an important study and enables comparison to more recent

stroke studies which have observed some of the same characteristics among the stroke

population today.

Regional stroke care in terms of urban and rural residence has important

implications on outcome and discharge of stroke patients. As stated previously, the

incidence of stroke is disproportionally distributed among the African-Americans

29


population, in comparison to Caucasian-Americans. However, in southwestern region of

the United States, a different disparity is observed. A study done in a South Carolina

hospital found stroke admissions to be highest among African-Americans compared to

Caucasian-Americans in age groups less than 85 years of age (Feng, 2009). Mortality

due to stroke has shown similar findings. A report further highlighting the disparity of

stroke within the American population stated, "Despite the enormous and growing

burden of stroke...the disease does not receive the attention it deserves"(Bonita, 2007).

Further examination of the geographical, age, racial and long term effects of this

disease, particularly as they relate to African-Americans, is important and will be the

focus of my research.

In contrast to the strong relationship of more severe cerebrovascular disease

among African-Americans, Caucasian-Americans have been found to have a greater

association with cerebral embolism, or transient ischemic attack (TIA), which is a less

severe stroke type(Gorelick, 1998). Variation of stroke occurrence has been observed

based on regional differences as well. On a global scale, transient ischemic attack (TIA)

has been found to prevalent in rural communities in north Portugal. The annual

incidence of TIA was slightly higher in rural communities, compared to urbah areas. In

this study, age proved to be a major factor of incidence of TIA. Patients 65 years and

older were at greatest risk of stroke occurrence following TIA with 12.8% of the

population experiencing a stroke event at within seven days of the TIA event (95% CI,

7.3 to 18.3) and within a year, 21.4% of this population experiencing stroke events (95%

CI 14.6 to 28.1) showing a significant difference stroke occurrence between populations

(M. Correia, M. R. Silva, R. Magalhaes, L. Guimaraes, & M. C. Silva, 2006). There is a

pattern of increased stroke related mortality in rural communities than in urban

communities in developed countries, or among countries in the world, where the risk of

30


stroke is higher among economically disadvantaged populations (Zhang, Guan, Mao, &

Liu, 2007) Stroke was 1.45 times more prevalent in rural areas than in urban areas in

the United States, 15.1 per 1000 (rural) and 10.4 per 1000 (urban). However, there is

little data on effective implementation of stroke care in rural systems of many developed

countries with care that encompass all aspects of stroke management such as the

United States(Joubert, 2008). More research must be done in the United States on rural

stroke management and data reporting.

31


METHODOLOGY

Type and Source of Data

Tennessee hospitals have the option to participate in the Tennessee Department

of Health, Division of Health Statistics Hospital Data Discharge System (HDDS).

Annually, in intervals separated into quarters, hospitals may submit their discharge data

to either the Tennessee Hospital Association Health Information Network (THA-HIN), or

the HDDS database. Patient records for the HDDS system are extracted from the UB-

04 form locator. This form is used for billing purposes and includes patient information

required for hospital admission and discharge. This patient data reporting option was

created through the requirements of T.C.A., Section 68-1-108 which states, "Each

licensed hospital shall report all claims data found on the UB-04 form or a successor

form on every inpatient and outpatient discharge to the commissioner of health"

(Tennessee Department of Health, Division of Health Statistics, 2007).

The purpose of the HDDS is to "collect and summarize hospital claims data so

charges for similar types of services may be analyzed and compared in order to promote

a more price competitive environment in the medical marketplace" (Tennessee

Department of Health, Division of Health Statistics, 2007). The data from the data

system and UB-04 form may also be used as a tool to gauge the delivery of healthcare

services to patients and has broad policy implications for shaping the future of our health

delivery system. Required discharge records included in the HDDS are all inpatient

32


records, emergency room records, ambulatory records, and diagnostic service records.

The stroke-related discharges included in this study are all patients admitted to the

hospital by any of these modes of entry.

Secondary data hospital discharge records have been used for this study. All

data includes records from discharges beginning January 1, 2000 through December 31,

2006. The first quarter of the HDDS system year begins January 1st and the final

quarter of the year ends on December 31st. Since all data was collected prior to 2008,

each year included in the study has the complete data from each quarter from 2000

through 2006. All personal identifiers were removed prior to receipt of the data due to

privacy regulations, and requirements of the Division of Health Statistics Institutional

Review Board approval (Appendix A). The study was approved by the Tennessee

Department of Health Institutional Review Board as well as the Meharry Medical College

Institutional Review Board.

The cerebrovascular disease patient discharge records were all accessed via the

HDDS. Patient records selected for analysis based on their primary diagnosis as

defined by ICD-9-CM code. The ICD-9-CM code describes the principal diagnosis,

which is the condition chiefly responsible for the admission of the patient for care. The

principal diagnosis code should reflect the information contained in the patient medical

record for their hospital stay (Tennessee Department of Health, Division of Health

Statistics, 2007). Only those ICD-9-CM codes that represented cerebrovascular disease

related to hemorrhagic, ischemic, or TIA were included in analysis. Hemorrhage

(subarachnoid hemorrhage (SAH) and intracerebral hemorrhage ICH): 430, 431,

respectively; ischemic stroke including: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91,

434.01, 434.11, 434.91, 436; and transient ischemic attack (TIA): 435.0, 435.1, 435.2,

435.8, 435.9 (Practice Management Information Corporation, 1994) (Appendix B)

33


Patient discharge status records were also considered in this analysis. Patient

patients discharge status (dependent variable), in the HDDS system included several

twenty-three different discharge codes. Patient discharge status was grouped in to three

different groups based on the patients discharge destination. Patient discharge status

was a dependent variable in the analysis. The patient discharge status is a code given

to each patient upon release from the hospital by their treating physician. Patient

discharge status was grouped into three primary groups: (1) those who were discharged

home; (2) those who were discharged to an assisted living facility or intermediate care;

and; (3) those who were discharged to an inpatient rehabilitation hospital or

institutionalized care.

Discharges were grouped based on the type of care and services available, and

patients' level of independence at discharge. All possible discharges in the HDDS

varied based on the condition of the patient at discharge, the type of insurance of each

patient, whether the patient refused care or died in the hospital. In this study however,

patients who died in the hospital due to stroke admission and those who "left against

medical advice," were not included. The independent predictor variables used to •

determine associations with hospital discharge status were: (1) patient's principal

diagnosis code, (2) patient's state of residence, (3) patient's zip code address, (4)

patient's date of birth, (5) patient's sex, (6) primary payer, (7) patient's race/ethnicity.

Each patient's principal diagnosis is based on the ICD-9-CM code describing the

principal diagnosis (i.e., the condition chiefly responsible for the admission of the patient

for care). The principal diagnosis code reflects the information contained in the patient

medical record for their hospital stay. Each patient's primary diagnosis was classified as

a three level categorical variable in the analysis: "hemorrhagic", "ischemic", or "transient

ischemic stroke".

34


Each patient's state was also extracted from the HDDS and considered in

analysis. All discharge records in analysis originated from Tennessee hospitals,

resulting in state not being included in the statistical model for data analysis. Also

extracted from the UB-04 from was, "patient's zip code address", which was defined by

the payer organization. This data is used to properly classify each patient county of

residence and to allow for analysis by place of residence. Data restrictions and patient

privacy limitations required that zip codes be listed as 3-digit zip codes for analysis. As

a result, only 3-digit zip codes were used to determine each patient's residence and

were classified as a categorical variable by either "urban" or "rural". Urban and rural

residence was determined based on data obtained from the 2000 Census summary file

3 (SF3) (U.S. Census Bureau, 2010). Total population urban and rural data was broken

down into levels based on characteristics of the 3-digit zip code. Characteristic levels

included total: urban area, inside urbanized area, inside urbanized clusters, rural area,

farm area, and non-farm area.

The Bureau of the Census defines urban as comprising all territory, populations,

and housing units located in urbanized areas and in places of 25,000 or more

inhabitants outside of urban areas. Urbanized areas (UA) are those that are

continuously built-up with a population of 50,000 or more. These areas were included in

the urban category. Rural places and territory are described as any incorporated place

or census designated places with fewer than 2,500 inhabitants located outside an

"urbanized area". These areas were included in the rural category. A place is either

entirely urban or entirely rural, except for those designated as an extended city, large

expanses of sparsely populated territory (U.S. Department of Commerce, Geography

Division, 1994). Based on the total population, patient's zip codes were coded based on

percentage of rural households in the region, or percentage of non-urban households.

35


Patient date of birth was also extracted from the HDDS to determine the age of

each stroke patient admitted. Patients included in the data set ranged from 1-99 years

of age. Age was split into three separate categorical groups based on stroke trends in

previous studies where age played a significant role, 18-39, 40-69, and 70-99 years of

age (Correia M. , Silva, Magalhaes, Guimaraes, & Silva, 2006). Patients aged 0-17

were excluded from analysis. Each patient's age is based on data collected at time of

admission. However, due to privacy and protected health information policies enforced

by Tennessee Division of Health Statistics, patients 90 years of age arid above are listed

as 99 years of age. This consideration will be taken into account in the analysis of data

and mentioned again in the discussion as a limitation of the study. Patient's age has

been classified as a continuous variable for data analysis.

Patient's sex was also taken into account in analysis of the stroke data. In some

stroke cases recorded and reported on the UB-04 forms, patients are listed as male,

female, or unknown. All cases listed as unknown were taken out of the data set for this

study and excluded from analysis. Patient's sex was classified as a categorical variable

in data analysis.

Primary payer (insurance provider) was also a variable from the UB-04 from used

for analysis. The primary payer organization is defined as "the name or type of payer

organization from which the hospital first expects payment for the bill" (Tennessee

Department of Health, Division of Health Statistics, 2007). The UB-04 form allows up to

three payers to provide payment for hospital services; however, the primary payer is the

most important because it is the first payer on each patients account. Each patient's

payment classification was divided into three general groups; public insurance

(TennCare, Medicare), private insurance (Other Insurance) and no insurance. Patients

who were classified as "self-pay" were coded as uninsured. Patient's payer

36


classifications were coded as categorical variables for analysis. Patients whose UB-04

form identified their primary payer classification as "free-care" or "unknown" were

excluded from analysis

Patient race/ethnicity is another variable used in analysis however it does not

appear on the UB-04 form. The field is required to be reported in addition to the data

elements contain on the UB-04. The patient race/ethnicity is included from the patients

chart, due to the fact that it is not included on the patient's record Patients whose

race/ethnicity listed as "unknown" were excluded from analysis. Other groups excluded

from analysis are listed in the Patient's race/ethnicity was classified as a categorical

variable in data analysis. In this study, only African-Americans and Caucasian-

Americans were considered.

Study Design

Analysis of hospital stroke-related data was conducted using a "between-

subjects" outcome based study design. Cerebrovascular ICD-9-CM diagnoses were

matched and grouped based on category of stroke and type. ICD-9-CMs of interest are

430, 431 (hemorrhage), 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,

434.91, 436 (transient ischemic attack) 435.0, 435.1, 435.2, 435.8,435.9 (acute

ischemic attack). These codes correspond to each category of the two groups of stroke

types and transient ischemic attack. Patient discharge status was categorized into three

levels of discharge based on desirability. The most favorable discharge setting is

discharge to home, and least favorable discharge setting is discharge to an inpatient

rehabilitation hospital or facility. The most favorable discharge status was held as the

reference group in the model, because it is associated with the most desirable stroke-

related hospital discharge conditions.

37


Independent variables: Insurance, stroke type, rural-urban residence, sex, age,

race/ethnicity, were analyzed to determine stroke-related discharge significance. Urban-

rural residence is based on 3-digit zip codes classification, age is determined by using

patient's birthdates, but patients ninety (90) years of age and above are reported as

ninety-nine (99). Insurance status was determined based on primary payer information

gathered from the admitting hospital, while race/ethnicity was collected based on

information reported from patient's hospital chart.

Statistical Model

Multinomial logistic regression was used to evaluate the dependent discharge

variable and independent predictor discharge variables with statistical software package

SPSS 18. The multiple logistic regression model incorporates one outcome variable

with multiple levels of outcome (i.e., patient discharge -to home, -to assisted living, -to

inpatient rehabilitation facility). The first outcome category (discharge to home), is set as

the reference group because it is the most favorable hospital discharge outcome, and for

the purposes of this study, creates the most significant comparison for association of

discharge statuses and patient characteristics.

Each of the independent predictor variables of the patients (age, race, sex,

insurance, and urban-rural residence) were ran in the regression model at the same

time. Multiple logistic regression statistical model enables estimation of multiple

outcomes with several different predictor variables. The logistic regression model

included two separate equations: patient discharge to an assisted living facility rather

than discharge home; and discharge to an inpatient rehabilitation facility rather than to

home (Appendix C). Discharge to home was held as a reference group in the model

because it was the most favorable hospital discharge outcome.

38


Analysis was carried out on all discharge records for all seven years in these two

multinomial logistic regression model equations to determine predictor variable

significance. Significance was defined using P-values and 95% CI. Non-significant

variables were removed one by one, by p-value, removing the largest first, until all

remaining variables in the model were significant. Significant variables were defined as

p<0.05. Odds ratios were used to determine direction and strength of variable

significance.

Research Hypotheses

Null Hypothesis (HOi)

There is no statistical relationship between the socio-demographic variables (race, sex,

and age), and stroke-related discharge status among Tennessee hospitals between the

years of 2000-2006.

Alternative Hypothesis (Ha!)

There is a significant statistical relationship between the socio-demographic variables

(race, sex, and age) and stroke-related discharge status among Tennessee hospitals

between the years 2000-2006.

Ho2: There is no statistical relationship between stroke patients' area of residence (rural-

urban), and hospital discharge status by Tennessee hospitals

Ha2: There is a statistical relationship between the area of residence of stroke patients

and hospital discharge status in Tennessee, using the period, 2000-2006.

39


HO3: There is no statistical relationship between the hospital discharge status of stroke

patients and health insurance status in Tennessee, using the period, 2000-2006.

Ha3: There is a statistical relationship between the hospital discharge status of stroke

patients in Tennessee and health insurance status, using the period, 2000-2006.

40


RESULTS

Among all hospitals in Tennessee who participated in the HDDS system between

2000 through 2006, there were 118,205 cerebrovascular cases reported to the

Tennessee Health Department's Division of Health Statistics. After excluding cases

based on previously mentioned criteria, the final study population consisted of 99,513

patients. This population was further broken down into groups based on discharge

status from the hospital as seen in Table 1. A majority of the patients discharged from

inpatient care were diagnosed with ischemic stroke and discharged to either a nursing

facility or an assisted living site.

This finding is in alignment with many of the studies of ischemic stroke and

rehabilitation discharge setting (Paolucci, et al., 2003). Patients whose primary

diagnosis was hemorrhagic stroke were discharged more often to either an

inpatient/hospital setting (13.9%) or to a nursing home or assisted living (9.5%). These

percentages are to be expected, admission to nursing homes following a hemorrhagic

stroke is less likely than other discharge settings (Brown, et al., 1999). Among patients

discharged to assisted living settings, over half (75%) of this population's primary

diagnosis was ischemic stroke rather than any other stroke type. More than half of the

patients diagnosed with stroke in the study population were diagnosed with ischemic

stroke. The average age of all patients discharged in the study was 70.6 years. Over

half of the population was female (58.3%), and the majority of the patients among any

41


discharge group were African-American (81.3%). These characteristics are consistent

with findings of previous studies which evaluated the impact of cerebrovascular disease

among African-American populations. Among both African-Americans (52.2%) and

Caucasian-Americans (13%), ischemic stroke was the most prominent primary diagnosis

for all patients discharged between 2000 through 2006. Among patients diagnosed with

ischemic stroke, a significantly larger amount of patients were assigned the primary

diagnosis code "436" (acute-but ill defined cerebrovascular disease). In comparison with

other diagnosis codes for ischemic stroke (25%), this was the most highly assigned

primary diagnosis. This could be due to regional differences in diagnosis patterns

between physicians, or a decline in physician's diagnosing other types of ischemic

stroke symptoms. All other stroke cases were similar in terms of occurrence from 2000

through 2006.

Between the years 2001 and 2002, there was a slight increase in all types of

stroke-related cases, hemorrhagic, ischemic or TIA, admitted and discharged from

Tennessee hospitals. Among hemorrhage stroke cases, subarachnoid (SAH) cases

made up the majority of hemorrhagic events with 7,010 cases (72.5%) between 2000

through 2006. Among transient ischemic attack (TIA) discharged cases, the majority of

the diagnosed patients were assigned the ICD-9-CM code 435.9, "unspecified transient

cerebral ischemia" Appendix B. This ICD-9-CM diagnosis comprised the majority of the

TIA discharged cases, consisting of 92.7% of all TIA diagnoses.

There were significant differences in urban and rural residence based on patient

discharge. In each discharge setting, there was a significant amount of patients

discharged to each location, although, nursing settings was had the majority of

discharges. Discharge to home and to hospital facilities was the discharge destination of

many people; however the majority came from rural zip-codes.

42


Table 1: Comparison of Cerebrovascular Disease Discharge Status for Demographic and Other Risk Factors.

Home Nursing or Similar Inpatient Hospital No.= 48,003 No. = 35,223 No. =16,287

Factor No. (%) No. (%) No. (%) Primary Diagnosis

Hemorrhagic 3,135(6.5) 3,355 (9.5) 2,212(13.6) Ischemic 25,034(52.2) 26,478 (75.2) 13,354 (82.0) TIA 19,834(41.3) 5,390 (15.3) 721 (4.4) Missing 0 0 0

Sex Male Female Missing

Age 18-39 40-69 70-99 Missing

Race/Ethnicity Black White Missing

Residence Urban Rural Missing

Primary Payer Public Private No.lnsurance Missing

21,846(45.5) 26,157 (54.5)

0

1,722 (3.6) 24,916(51.9) 21,365 (44.5)

0

38,934 (81.1) 9,069 (18.9)

0

15,044 (31.3) 32,796 (68.3)

163 (0.40)

29,036 (60.5) 12,881 (26.8)

6,086 (12.7) 0

12,509 (35.5) 22,714 (64.5)

0

286 (0.80) 8,845 (25.1) 26,092 (74.1)

0

29,327 (83.3) 5896 (16.7)

0

8,858 (25.2) 26,297 (74.7)

68 (0.10)

27,393 (77.7) 3,303 (9.4)

4,527(12.9) 0

7,073 (43.4) 9,214 (56.6)

0

315(1.9) 6,442 (39.6) 9,530 (58.5)

0

12,607 (77.4) 3,680 (22.6)

0

6,165 (37.9) 10,070 (61.8)

52 (0.30)

10,946 (67.2) 3,145(19.3) 2,196(13.5)

0

Using multinomial logistic regression model, all variables were assessed to

determine significance to discharge status, (Tables 2,3), significant variables were

determined based on p-value<0.05. Table 2 reports all significant variables in the model

which are statically significant to post-stroke event, patients discharged to home or

43


under self-care. All variables in this initial analysis proved to be significant with a p-value

of .000. Variables with a positive association included, hemorrhagic stroke (OR 6.39,

95% CI 5.99-6.791), ischemic stroke (OR 4.65, 95% CI 4.78-4.82), and having a "public"

insurance carrier (OR 1.20, 95% CI 1.15-1.26). Based on the model, these three

variables most significantly contributed to discharge to an assisted living facility, rather

than discharge to home. A positive association with discharge to an assisted living

setting suggests that when an individual is diagnosed with an ischemic or hemorrhagic

stroke, and has public insurance, there is a strong-likelihood of that patient being

discharge to an assisted living setting, instead of being discharged home. Variables with

a negative association were urban residence (OR 0.68, 95% CI 0.66-0.71), male sex

(0.72, 95% CI 0.70-0.74), African-American race (OR 0.84, 95% CI 0.81-88), private

insurance coverage (OR 0.57, 95% CI 0.53-0.60), and individuals ages 18-30 (OR 0.15,

95% CI 0.13-0.17) and 40-69 (OR 0.33, 95%CI 0.32-0.34).

There was a negative interaction of variables was determined using the

regression interval "B". When the regression interval is negative, this suggests an

inverse relationship between discharge statuses. This inverse relationship reveals that

instead of these variables favoring discharge to an assisted living facility, there is an

association with discharge to home. Urban residence, male sex, African-American race,

having private insurance, and individuals younger than 69 years of age have a stronger

likelihood of being discharged home rather than to an assisted living facility. This is the

inverse of the positive relationships.

44


Table 2: Patient Hospital Discharge to Assisted Living Facility

95%

Confidence

Interval for

Exp(B)

Std. Exp(B)" Lower Upper

B Error Wald df Sig. EXP(B) 1 Bound Bound

Intercept -.639 .034 352.119 1 .000

[Urban] -.386 .019 427.724 1 .000 .680 1.471 .655 .705

[Male] -.332 .016 433.976 1 .000 .718 1.393 .696 .740

[Hemorrhagic] 1.853 .032 3399.351 1 .000 6.381 — 5.996 6.791

[Ischemic] 1.536 .019 6644.858 1 .000 4.648 — 4.479 4.823

[AA]

CM r̂

-

.022 60.114 1 .000 .842 1.188 .806 .879

[Public] .182 .023 61.952 1 .000 1.200 — 1.146 1.255

[Private] -.570 .031 342.612 1 .000 .566 1.767 .532 .601

[18-39] -1.880 .067 794.148 1 .000 .153 6.536 .134 .174

[40-69] -1.109 .018 3715.178 1 .000 .330 3.030 .318 .342

The reference category is: Discharge TO HOME.

A secondary determinant of significance was based upon the 95% confidence

intervals. Significance was determined based on whether 1.00 was outside of both the

lower and upper bounds of the intervals. In all significant variables in the equation

comparing assisted living discharge to discharge home, this was apparent.

Table 3 reports all variables that were significant to the relationship of patients

being discharge to an inpatient rehabilitation facility versus discharged home. A positive

relationship was also found again with hemorrhagic stroke (OR 24.71, 95% CI 22.49-

27.15) and ischemic stroke (OR 15.84, 95% CI 14.66-17.13) diagnoses.

45


Table 3: Patient Hospital Discharge to Inpatient Rehabilitation Facility

95%

Confidence

Interval for

Exp(B)

Std. Lower Upper

B Error Wald df Sig. Exp(B) Exp(B)"1 Bound Bound

Intercept -2.938 .053 3038.004 1 .000

[Urban] .169 .022 58.632 1 .000 1.184 — 1.134 1.237

[Male] -.096 .020 23.889 1 .000 .909 1.100 .874 .944

[Hemorrhagic] 3.207 .048 4455.145 1 .000 24.713 — 22.492 27.154

[Ischemic] 2.763 .040 4824.830 1 .000 15.849 — 14.660 17.134

[AA] -.141 .026 29.284 1 .000 .868 1.152 .825 .914

[Public] .045 .029 2.423 1 .120 1.046 — .988 1.108

[Private] -.215 .035 37.213 1 .000 .806 1.241 .752 .864

[18-39] -1.168 .067 306.916 1 .000 .311 3.663 .273 .354

[40-69] -.665 .022 874.177 1 .000 .514 2.032 .492 .537

The reference category is: Discharge TO HOME

Similar to the first equation, public insurance (OR 1.05, 95% CI 0.99-1.11) had a

positive association with discharge to an inpatient rehabilitation facility, rather than

discharge to home. Variables that were found to have a positive association with

discharge to an inpatient rehabilitation facility, instead of being discharged home were a

significant contributor to determination of discharge destination. All of the same

variables that had a negative relationship with discharge to an assisted living setting

(male [OR 0.91, 95% CI 0.87-0.94], African-American race [OR 0.87 95% CI 0.83-0.91],

private insurance coverage [OR 0.81, 95% CI 0.75-0.86), ages 18-39 [OR 0.31, 95% CI

0.27-0.35] and ages 40-69 [OR 0.51, 95% CI 0.49-0.54], were found to also have a

negative relationship with discharge to an inpatient rehabilitation facility. However, unlike

the assisted living versus home equation, urban residence (OR 1.18, 95% CI 1.13-1.23) 46


had a positive association with discharge to an inpatient rehabilitation facility, instead of

discharge home.

47


DISCUSSION

The trends in discharge status among stroke survivors in Tennessee between

2000 through 2006 showed that a majority of patients were discharged home. Table 1

shows that nearly half (48.2%) of stroke survivors were discharged home. This finding

suggests that stroke patients who were well enough to return home were able to

successfully complete the activities of daily living, suggesting that their individual stroke

severity was not indicative of discharge to an intermediate or inpatient rehabilitation

facility. In this study, patient with any combination of the following patient characteristics

consistently contributed to discharge home rather than to any other discharge setting

included patients who were male, African-American, have a private insurance carrier,

and are 69 years of age or younger. Patients with these characteristics, based on these

results, have tend to either have the most favorable outcomes post stroke, or have other

contributing factors that inhibit discharge to a rehabilitation facility. Which also

introduces the possibility that discharge home may not be indicative of the most

favorable post-stroke outcomes, instead this could be due to lack of insurance or assets

to provide for post-hospital discharge care.

Ischemic stroke is the most common subtype of stroke* (Asylanyan, Weir, Lees,

Reid, & Gordon, 2003), Table 1 also reflects these results, in that ischemic stroke made

up at least half of the population in each discharge destination. However, as can be

assumed, a larger amount of patients were discharged home who were diagnosed with

48


transient ischemic attack, rather than the other discharge destinations. There were a

larger amount of female stroke survivors, in comparison to males, and patients with

public insurance were discharged to each destination more often than any other

insurance carrier.

African-Americans composed a significant portion of the study population. Each

discharge destination was exceedingly populated by African-Americans; discharge to

home, to assisted living, and inpatient rehabilitation facility. This trend in racial

differences in the study population partially explains the differences observed in payer

classification. The majority of stroke surviving patients discharged had a public

insurance carrier. Several studies have pointed out that Caucasian-Americans were

more likely not to have a public insurance carrier, (Gorelick P. B., 1998), (Ottenbacher,

Campbell, Kuo, Deutsch, Ostir, & Granger, 2008). Rural residents composed the

majority of the population, meaning that several stroke surviving patients' originate from

rural area. These results however cannot be generalized to other areas because the

urban-rural coding classification system was not 100% reliable.

Patient Discharge to Assisted Living Setting vs. Home

Through multinomial logistic regression, statistical relationships were found

between predictor variables and discharge status. For statistical analysis, discharge to

home was set as the reference group, because it was considered the most favorable

discharge outcome post-stroke. Through analysis of discharge to assisted living care

versus discharge to home, the results showed positive and negative relationships

between many of the variables. Among those variables with a positive relationship,

patients diagnosed with hemorrhagic stroke had a strong relationship with discharge to

nursing facility, rather than discharge to home. Hemorrhagic diagnosed patients

49


suffered six times more risk of being discharged to an assisted living environment, rather

than being discharged home. Also, among predictor variables with positive

relationships, patients diagnosed with ischemic stroke were about five times more at risk

of being discharged to assisted living care, rather than to self-care at home. Based on

the literature, (Paolucci, et al., 2003), these results are to be expected because stroke

severity is considered the most powerful prognostic factor. Both disability and

neurologic impairment are consequences of stroke onset among ischemic and

hemorrhagic stroke types. The final variable with a positive relationship among

discharge to assisted living care versus discharge to home was public payer

classification. Patient's who insurance carrier was a public entity were 1.2 times more at

risk of being discharged to an assisted living environment rather than to home. Public

insurers in this study included Medicare and TennCare, and according to these results,

stroke patients with either of these insurance carriers were more likely to be discharged

to assisted living rather than to home.

Additionally, other variables significant to the assisted living and discharge to

home relationship were urban residence, male, African-Americans, private insurance,

and the age groups 18-39 and 40-69. Patients who were from an urban residence

based on their three digit zip code found that patients from urban residences were 1.5

times more likely to be discharged home rather than to an assisted living environment.

As opposed to rural, this is to be expected from the literature which found that more

severe stroke cases are observed in rural areas (Zhang, Guan, Mao, & Liu, 2007).

These results equate to several different factors that deal with access and availability of

different levels of post-stroke services. In rural areas, the level of access is much

different from that available in urban area. As a result many stroke patients are either

left to find alternative modes of the treatment.

50


Males were found to be, 1.5 times more likely to be discharged home, rather than

to be discharged to assisted living facilities. According to the literature, these results are

supported, in that previous studies have also found that pre-stroke and post-stroke

disability and institutionalization rates were significantly higher among females. Since

sex differences in stroke began to be recognized, the particular influence of estrogen

and testosterone on the endothelium and the vascular system, the role of risk factors

unique to women such as the use of oral contraceptives, hormone replacement therapy,

and pregnancy, systemic delays in the recognition, and insufficient treatment of

conventional stroke risk factors in women have all been considered as probable

explanations (Petrea, Beiser, Seshadri, Kelly-Hayes, Kase, & Wolf, 2009). African-

Americans were found to have a negative relationship with discharge to both assisted

living and inpatient rehabilitation settings. In fact, African-American Tennesseans were

found to be almost two times as likely to be discharged home, rather than any other

discharge setting when compared to Caucasian-American Tennesseans. This can be

due to several different factors, including limitations from insurance coverage, or lack of

assets to afford post hospital stroke care. This is important to distinguish because the

assumption that African-Americans experience better outcomes in comparison to

Caucasian-Americans simply because they are discharged home post-stroke instead of

to an intermediate or intensive care settings is not entirely accurate in all situations. In

an study which analyzed the racial impact of post-stroke outcomes found that African-

American Stroke patients has greater functional impairment initially and improved more

slowly in comparison to Caucasian-Americans (Horner, Matcher, Divine, & Feussner,

1991)

The other side of this result of African-Americans post-stroke discharge is that

African-Americans have access to care from family or loved ones at home. A study

51


which supports these results is observed in a study that found Caucasian-Americans to

be less likely discharged home in comparison to African-Americans, 66% vs. 75%,

respectively (Ottenbacher, Campbell, Kuo, Deutsch, Ostir, & Granger, 2008). These

results are not as one would expect, because African-Americans have been found to

suffer from more severe strokes than Caucasian-Americans. However, discharge

disposition is a complex variable with many potential mediating factors; in this case it is

possible that family support and social network structure are much significant in African-

American households. Patient and family preferences play a major role in patient

discharge and placement. African-American tend to view nursing homes more

negatively, in addition the patient population consisting of minorities in nursing facilities

are quite low (Miller, McFall, & Campbell, 1994).

As a result, African-American families may be more willing to encourage home

placement for stroke survivor's care rather to utilizing assisted living facilities. Private

insurers also contributed a negative relationship to discharge to assisted living settings.

Privately insured patients who were stroke survivors were almost two times as likely to

be discharged to home, rather than to an assisted living facility. This is congruent with

the literature because privately insured patients are more likely to undergo primary or

secondary prevention in the absence of acute stroke symptoms (Shen & Washington,

2007). Many patients who are privately insured have access to services uninsured and

publicly insured patients do not have, as a result, many the stroke cases among this

population of patients have better outcomes (Shen & Washington, 2007).

Lastly, among variables that have a negative relationship to the equations,

discharge to an assisted living environment versus discharge home is age, specifically

patients 18-39 and 40-69. Patients in these two groups are the youngest in the study

and were found to be almost seven times as likely to be discharged home (18-39 years

52


of age) rather than to a nursing facility, and three times as likely to be discharged home

(40-69 years of age) rather than to an assisted nursing facility. These results are to be

expected among younger individuals. A majority of stroke cases are found in the age

group 65 years of age and older, with the worst outcomes. In addition, the primary

composition of rehabilitation facility consists of patient in this age group (Schlegel,

Tanne, Demchuk, Levine, & Kasner, 2004). These results are congruent with that of

previous studies.

Patient Discharge to Inpatient Rehabilitation Setting vs. Home

In this study, discharge to an inpatient rehabilitation facility was considered the

most severe post-stroke outcome. This was classified as such because discharge to an

inpatient rehabilitation facility calls for intensive treatment, and usually at initial discharge

suggests that the patient is not able to care for himself or herself at any level. Similar to

the assisted living discharge and home, several variables also had positive and negative

relationships with discharge to inpatient rehabilitations setting and discharge to home.

Variables which had a positive relationship discharge to inpatient rehabilitation facilities

were urban residence, hemorrhagic or ischemic primary diagnosis and public insurance.

Based on three digit zip codes, patients from urban residences had 1.2 times the

risk of being discharged to an inpatient rehabilitation facility instead of to home. Rural

patients had a better chance of being discharged home post-stroke than non-rural

residents. There is little research available on the distinction between discharge

between urban and rural residence, however these results suggest that patients from

rural residence are able to be discharge home. These results also suggest that due to

the lack of complete comprehensive care in rural areas, the availability of intense

rehabilitative care may not be readily available in rural areas. For this reason, some

53


patients may not be able to go directly to a high level of care such as .an inpatient

rehabilitative setting. Primary diagnosis was found to be a strong predictor of discharge

to inpatient rehabilitation facility. Hemorrhagic stroke had a strong positive relationship

with discharge to inpatient rehabilitation versus discharge to home. Hemorrhagic stroke

patients had 24 times greater risk of being discharged to rehabilitation settings as

opposed to home. In addition, ischemic stroke patients also had a significantly

increased risk of being discharged to an inpatient rehabilitation facility. Ischemic stroke

patients had 15 times greater risk of discharge to an inpatient rehabilitation environment

as opposed to discharge to self-care at home.

Once again, these results are to be expected, in that these two stroke categories

are the most severe manifestations of cerebrovascular disease, and cause neurological

impairment and disability. As a result these patients are at a greater risk of being

discharged to an inpatient rehabilitation facility (Paolucci, et al., 2003). Similar to

patients discharge to assisted living setting, patient whose primary payer was a public

insurer had a onetime increased risk of being discharged to an inpatient rehabilitation

facility, as opposed to being sent home post-stroke.

Patient predictor characteristics that had a negative relationship stroke discharge

to an inpatient rehabilitation setting were: males, African-Americans, and age 18-39 and

40-69. Males were one times more likely to be discharged home, rather to an inpatient

rehabilitation facility. This is an important observation because similar to effects due to

stroke observed among women; men have a greater likelihood of being discharged

home. A study that explored the short-term follow up disability and outcomes at 3 and 6

months after stroke, found that women were more likely to be disabled than men, and

the rates of institutionalization significantly favored women, with almost 4 times as that of

men (Petrea, Beiser, Seshadri, Kelly-Hayes, Kase, & Wolf, 2009). The rates of

54


discharge "to home", as opposed to discharge to an inpatient rehabilitation facility by

race/ethnicity, found that African-Americans 1.2 times more likely to be discharge home,

rather than to an inpatient rehabilitation facility when compared to Caucasian-Americans.

Similar to results found among patient discharged to assisted living settings, this trend

among African-Americans in likely due to social and family support to encourage

discharge to home rather than to inpatient rehabilitation.

Lastly, age had a negative relationship as a predictor variable of discharge to an

inpatient rehabilitation setting. Patients 18-39, were 3.6 times as likely to be discharged

home rather than to be discharged to a rehabilitation facility. Also, patients 40-69 we re

2.0 times as likely to be discharged home instead rather than to an inpatient

rehabilitation setting. The strength of association is not as strong as the association

observed in discharge to an assisted living setting, however the trend is observed.

Younger stroke survivors are more likely to be discharge home rather than to require a

form of rehabilitation. This is to be expected because many of age is a strong predictor

to cause stroke and require rehabilitative services.

Study Strengths and Limitations

Study Limitations

The use of secondary data in this study was a limitation of the research. Each of

the variables that were used had a predetermined standard of its composition. The

study was restricted to variables that were only listed on the UB-04 form in the data used

for the study. Hpwever, using the HDDS system was also strength of this study was

well. The data collection system is uniform for all hospitals that participate in the data

system. Since there is a uniform design to data collection, the system variables are

more reliable for analysis of data. Another limitation of the study was the urban-rural

55


classification system. Due to data restrictions and privacy regulations, for analysis urban

and rural distinctions were made based on 3-digit zip codes. Using 3-digit zip codes to

classify urban and rural residence is net a 100% accurate classification system. Also,

the classifications for urban-rural residence in this study were made using 2000, census

data. As a result, the urban-rural classifications may not be as accurate in each year.

Finally, this study did not account for double counting in coding and classification. As a

result, some patients discharged from one hospital may also be counted as new patients

from another hospital.

Study Strengths

There were several strengths of this study that contributed to the reliability and

significance of the results. These strengths included:

1) A major strength of this study was the large sample population used. The

sample size of 99,513, may have significantly contributed to the significance of

many of the variables used.

2) An additional strength of this study is the use of ICD-9-CM diagnosis codes.

Previous studies have pointed out the reliability that diagnosis codes have in

classifying patients, specifically patients with hemorrhagic stroke and transient

ischemic attack (Benesch, Witter, Wilder, Duncan, Samsa, & Matchar, 1997).

3) A final strength of this study was the geographic difference in Tennessee

regarding the urban and rural areas. Tennessee has a large rural population,

and the distinctions between these two areas in the state are significant. The

research in this study shows the differences between these two areas as far as

stroke discharge is concerned, however more research should be done regarding

the urban and rural regions in Tennessee.

56


REFERENCES

57


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2. American Stroke Association. (2009,12 17). Types of Stroke. Retrieved 2 2, 2010, from Stroke Association: http://www.strokeassociation.org/presenter.jhtml?identifier=1014#lschemic

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APPENDICES

63


APPENDIX A

MEHARRY M E D I C A L C O L L E G E

OFFICE FOR RESEARCH

Institutional Review Board

Februaiy 24,2010

Edward Davis Jr.

Division of Public

Health Practice

Meharry Medical

College Nashville, TN

37208

RE: Association of stroke-related hospital discharges with socio-demographic

characteristics, insurance status, and urban-rural residence in Tennessee (MSPH

thesis)

;

Dear Mr. Davis: -

The Institutional Review Board has determined that the project above is exempt based on category 45CFR 46.101(b) (4) of the federal regulations concerning the use of existing records, data, pathological specimens or diagnostic specimens when the information is recorded by the investigator in such a manner that subjects cannot be identified. No consent form is needed.

If you have any questions regarding this please feel free to contact me or Cynthia Weaver at 6735. Sincerely,

2/24/2010

Cynthia Weaver Cynthia Weaver, MT(ASCP), MSPH

Human Protections Administrator

100219ED034 1005 Dr. D.B. Todd Jr. Boulevard

Nashville, Tennessee 37208-3599

T:615.327.6735 | F:615.327.6391 | www.mmc.edu

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APPENDIX B

ICD-9-CM Cerebrovascular Disease Diagnosis Codes

ICD-9 Code

DescriDtion ICD-9 Code

Descriotion

430 Subarachnoid hemorrhage 434.91 Cerebral artery occlusion unspecified with cerebral infarction

431 Intracerebral hemorrhage 435.0 Transient cerebral ischemia of basilar artery syndrome

433.01 Occlusion and Stenosis of basilar artery with cerebral

435.1 Transient cerebral ischemia of vertebral artery syndrome

433.11 Occlusion and Stenosis of carotid art en/ with cerebral infarction

435.2 Transient cerebral ischemia subclavian steal syndrome

433.21 Occlusion and Stenosis of vertebral artery with cerebral infarction

435.8 Transient cerebral ischemia and other specified transient cerebral ischemia

433.31 Occlusion and Stenosis of multiple and bilateral precerebral arteries with cerebral infarction

435.9 Transient cerebral ischemia or unspecified transient cerebral ischemia

433.81 Occlusion and Stenosis of other specified precerebral artery with cerebral infarction

436 Acute, but ill-defined, cerebrovascular disease

433.91 Occlusion and Stenosis of unspecified precerebral artery with cerebral infarction

434.01 Cerebra) thrombosis with cerebral infarction

434.11 Cerebral embolism with cerebral infarction

•

65


APPENDIX C

Equation 1, 2: Multiple Logistic Regression Model for Hospital Discharge

Description Equation

1 Discharge to Assisted Living Facility / Discharge to Home

[P(Y=yji|x)r/P(Y=yc|x)r = eaJ1

_p X +p X X +p X +p X e j1 1 j2 2 j3 3 j4 4 j5 5

2 Discharge to Inpatient Rehabilitation Facility / Discharge to Home

[P(Y=yj2|x)r/[P(Y=yc|x)r=eaj2

-p x +p x +p x +p x +p x e j1 1 j2 2 j3 3 j4 4 j5 5

*Where[P(Y=yjlx)] =e>/£[e^,,2„.Lj= 1, 2,..c

"j" - indexes the outcome categories: 1= Discharge to assisted living facility , 2= Discharge to inpatient rehabilitation facility.

"cij and p/' - are unknown parameters

"X" - is the explanatory variables (i.e., age, race, sex, insurance, urban-rural residence)

66


VITA

Edward Mitchell Davis Jr., was born on September 24, 1982 in San Diego,

California. Edward also attended high school in San Diego, at St. Augustine High

School and graduated with his high school diploma in June of 2001. Following high

school, Edward attended Fisk University in Nashville, Tennessee, to pursue a Bachelors

of Science degree in Biology, which he received in May of 2006. He earned his Master

of Science in Public Health in May of 2010, from Meharry Medical College, which is also

located in Nashville, Tennessee.

At various points throughout his graduate education at Meharry Medical College,

he was awarded several academic accolades. During the 2008-2009 academic school

year he was awarded the honor of "Who's Who Among Graduate Students." During the

2009-2010 academic school year he was once again awarded "Who's Who Among

Graduate Students" and also received the "Multi-Greek Scholarship" given to a graduate

student for school participation while maintaining a impressive academic marks.

Many of Edward's professional interests have been shaped by his strong interest

in public health, patient care, and racial-related health disparities. Each of his

professional experiences has also been rooted in these interests as well. Between July

and May of 2009, he worked as an administrative assistant at Erlanger Health Systems

in Chattanooga, Tennessee provided by Tennessee Hospital Association (THA). This

was an opportunity to work with and develop diversity hospital policies and procedures.

67


From September 2006 to August 2008, Edward worked at an occupational and industrial

clinic in San Diego, California named South Coast Medical Clinic.

Edward's research experience began in 2006 while at Fisk University in

Nashville, Tennessee with an independent genetics based research project that involved

analyzing various stages of gestational development of the Xenopus Laevis (African

clawed frog), when eggs are exposed to different media.

Edward's future career goals and objectives are to become a public health

dentist; addressing the problems of oral health on the population level both through

patient care and policy implementation. In addition, he plans to address the oral health

disparities that affect African-Americans most prevalently, while improving dental and

oral health related disparities in low income urban communities.

Edward has a strong desire to serve his community which is shown through his

community service efforts and community involvement. In November 2008 and 2009,

Edward participated in "Community Day" at Meharry Medical College in Nashville,

Tennessee. He also volunteers with "Feed the Children" in Nashville, Tennessee, an

organization that is responsible for collecting and distributing food to families in need

domestically and internationally. Also in October of 2008 and 2009 he helped organize

two service drives; at Meharry Medical College, as a member of Kappa Alpha Psi

Fraternity named, "Kandy for Kids," and a men's clothing drive.

68


Documents

Association Between Stroke-related Hospital Discharge Status and Socio-Demographic Characteristic in Tennesse