Mexican American stroke survivors in a South Texas study, were more likely to use less intensive forms of rehabilitation services than their non-Hispanic white peers, and nearly one-third of all the stroke survivors did not receive any rehabilitation within 90 days of their stroke, according to preliminary research to be presented at the American Stroke Association's International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.
Even though stroke death rates among Mexican Americans are lower than their non-Hispanic white peers, previous research has shown that they often have worse outcomes and suffer greater disability after their stroke. One factor contributing to how well stroke survivors recover is the type of rehabilitation they receive in the window of time after the stroke, explained lead study author Lynda Lisabeth, Ph.D., M.P.H., a professor of epidemiology at the University of Michigan in Ann Arbor.
The more intensive forms of stroke rehabilitation that are provided at inpatient or skilled nursing facilities have better outcomes than less intensive forms of rehabilitation. Our objective was to identify what factors may impact the type of rehabilitation a person gets. We want to know if there are barriers to getting the most intensive level of rehabilitation, then we can develop interventions that target those barriers, which will help to maximize rehabilitation across the board and potentially reduce these disparities."
Lynda Lisabeth, Ph.D., M.P.H., professor of epidemiology at the University of Michigan in Ann Arbor
Researchers examined the link between ethnicity and the use and type of rehabilitation accessed by stroke survivors during the first 90 days after a stroke. They enrolled 554 participants from a South Texas community in the Brain Attack Surveillance in Corpus Christi Project (BASIC) soon after their stroke. Two-thirds of the participants were Mexican American adults (66%), and one third were non-Hispanic white adults. Nearly half were women, and the median age was 66 years.
The study was conducted between 2019 and 2021. During this period researchers conducted telephone interviews to determine the type of rehabilitation the stroke survivors received after hospital discharge, such as: outpatient, home health, inpatient or a skilled nursing facility. Participants were called every two weeks for three months and asked about their care. Based on in-person and telephone interviews, assessments were made of functional ability and depression at 90 days, along with information about the type of post-discharge care received.
The study found:
- One-third of all study participants did not receive any type of rehabilitation during the three months after their stroke.
- Two thirds (67%) of Mexican American stroke survivors, compared to just over half (56%) of non-Hispanic white peers, received some form of post stroke rehabilitation.
- Mexican American stroke survivors were younger (median age of 65 vs. 70 for non-Hispanic whites), had lower levels of education and income, more health problems, higher average body mass index, and worse functional outcome and depression at 90 days compared to non-Hispanic white peers in this study.
- After accounting for multiple factors such as age, income and other health conditions, Mexican American stroke survivors had almost two times higher odds of using any rehabilitation than non-Hispanic white stroke survivors.
- Mexican American stroke survivors were more likely to use outpatient (11% vs. 5%, respectively) and home health rehabilitation (38% vs. 30%, respectively) when compared to their non-Hispanic white peers.
- There were no major differences in the use of inpatient rehabilitation and skilled nursing facilities between the Hispanic and non-Hispanic white groups.
"There are many factors that drive the type of rehabilitation stroke survivors receive or if they can access rehabilitation. We want to better understand the barriers and preferences of Mexican American stroke survivors, so we may help develop culturally sensitive interventions that may increase the chances of stroke survivors going to inpatient rehabilitation, which contributes to better recovery," Lisabeth said.
The study is limited by its small size and its focus on one community in South Texas (Nueces County, Texas), which suggests these results may not apply to other communities across the country. "This community has a higher proportion of Mexican American people in an urban setting with a unique availability of rehabilitation. The study also took place over a period of time that overlapped with the COVID-19 pandemic," Lisabeth said.
The researchers note future studies focused on barriers and facilitators to intensive rehabilitation, especially among Mexican American stroke survivors, may be a way to reduce disparities and make substantial improvements in recovery.
The American Heart Association/American Stroke Association's 2021 Clinical Performance Measures for Stroke Rehabilitation: Performance Measures were developed to focus on key aspects of stroke rehabilitation that are important to maintaining quality of care for stroke patients. They cover various aspects of stroke rehabilitation in the acute, post-acute inpatient, outpatient and home settings.
According to those measures, stroke is among the most common causes of acquired disability among adults in the United States, with more than 7 million Americans over 20 years of age having experienced a stroke in the past and almost 2.5% of Americans reporting that they are disabled as a result of stroke. People in the U.S. discharged from the hospital after stroke received their rehabilitation care at either an inpatient rehabilitation facility (19%), skilled nursing facility (25%) or through home care services (12%).
"Rehabilitation after a stroke is a key factor in recovery and the return to independent functioning," said Joel Stein, M.D., FAHA, chair of the writing group for the American Heart Association/American Stroke Association clinical performance measures and the Simon Baruch Professor and chair of the department of rehabilitation and regenerative medicine at Columbia University's Vagelos College of Physicians and Surgeons; professor and chair of the department of rehabilitation medicine at Weill Cornell Medicine; and physiatrist-in-chief at NewYork-Presbyterian Hospital. "Exploring differences in care and disparities is an essential method of understanding gaps in care and improving systems of care for stroke survivors. Many factors may influence the delivery of rehabilitation care post-stroke. Stroke survivors with substantial impairments who have fewer financial resources and less social support may struggle with direct discharge from the hospital to home." Dr. Stein was not involved in this study.