Lesli E. Skolarus

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans

To determine trends in ischemic stroke incidence among Mexican Americans and non‐Hispanic whites.

Traumatic brain injury may be an independent risk factor for stroke

Objective: To explore whether traumatic brain injury (TBI) may be a risk factor for subsequent ischemic stroke. Methods: Patients with any emergency department visit or hospitalization for TBI (exposed group) or non-TBI trauma (control) based on statewide emergency department and inpatient databases in California from 2005 to 2009 were included in a retrospective cohort. TBI was defined using the Centers for Disease Control definition. Our primary outcome was subsequent hospitalization for acute ischemic stroke. The association between TBI and stroke was estimated using Cox proportional hazards modeling adjusting for demographics, vascular risk factors, comorbidities, trauma severity, and trauma mechanism. Results: The cohort included a total of 1,173,353 trauma subjects, 436,630 (37%) with TBI. The patients with TBI were slightly younger than the controls (mean age 49.2 vs 50.3 years), less likely to be female (46.8% vs 49.3%), and had a higher mean injury severity score (4.6 vs 4.1). Subsequent stroke was identified in 1.1% of the TBI group and 0.9% of the control group over a median follow-up period of 28 months (interquartile range 14–44). After adjustment, TBI was independently associated with subsequent ischemic stroke (hazard ratio 1.31, 95% confidence interval 1.25–1.36). Conclusions: In this large cohort, TBI is associated with ischemic stroke, independent of other major predictors.

Neurological, Functional, and Cognitive Stroke Outcomes in Mexican Americans

Background and Purpose— Our objective was to compare neurological, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites using data from a population-based study. Methods— Ischemic strokes (2008–2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days poststroke) and medical records. Ethnic differences in neurological (National Institutes of Health Stroke Scale: range, 0–44; higher scores worse), functional (activities of daily living/instrumental activities of daily living score: range, 1–4; higher scores worse), and cognitive (Modified Mini-Mental State Examination: range, 0–100; lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors. Results— A total of 513, 510, and 415 subjects had complete data for neurological, functional, and cognitive outcomes and covariates, respectively. Median age was 66 (interquartile range, 57–78); 64% were MAs. In MAs, median National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living, and Modified Mini-Mental State Examination score were 3 (interquartile range, 1–6), 2.5 (interquartile range, 1.6–3.5), and 88 (interquartile range, 76–94), respectively. MAs scored 48% worse (95% CI, 23%–78%) on National Institutes of Health Stroke Scale, 0.36 points worse (95% CI, 0.16–0.57) on activities of daily living/instrumental activities of daily living score, and 3.39 points worse (95% CI, 0.35–6.43) on Modified Mini-Mental State Examination than non-Hispanic whites after multivariable adjustment. Conclusions— MAs scored worse than non-Hispanic whites on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial.

Understanding Stroke Survivorship Expanding the Concept of Poststroke Disability

Background and Purpose— Limitations in essential daily activities are common among older adults after stroke, but little is known about restrictions in their ability to participate in valued social activities. We sought to broaden our understanding of disability after stroke by characterizing poststroke participation restrictions and investigating the extent to which they are accounted for by differences in physical and cognitive capacity, aphasia/dysarthria, depressive, and anxiety symptoms. Methods— Data from the 2011 National Health and Aging Trends Study (NHATS) were used to identify 892 self-reported stroke survivors aged ≥65 years. One-to-one propensity matching was performed on demographics and comorbidities to create a matched sample. Participation restrictions were defined as reductions/absence in social activities valued by respondents because of their health or functioning. Physical and cognitive capacity, depressive and anxiety symptoms were measured by validated scales and aphasia/dysarthria by a single question. Comparisons using survey-weighted &khgr;2 tests and logistic regression were made. Results— Stroke survivors had more participation restrictions (32.8% versus 23.5%; odds ratio, 1.59; 95% confidence interval, 1.28–1.95; P<0.01) than controls. Differences between stroke survivors and controls in any participation restriction and several components (attending religious service, clubs/classes, and going out for enjoyment) were eliminated after adjusting for physical capacity. Depressive and anxiety symptoms and aphasia/dysarthria were independent predictors of participation restrictions. Conclusions— Stroke survivors have more participation restrictions than can be accounted for by sociodemographic profiles and comorbidity burden. Future work aimed at improving physical capacity, reducing depressive and anxiety symptoms, and improving aphasia/dysarthria has potential to enhance participation.

Use of BPPV Processes in Emergency Department Dizziness Presentations: A Population-Based Study

Objective A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use. Study Design Prospective population-based surveillance study. Setting Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011. Subjects and Methods Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability. Results A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use. Conclusion Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.

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

Objective: We sought to characterize racial differences in disability among older stroke survivors. Methods: A cross-sectional study of 806 self-reported stroke survivors from the 2011 National Health and Aging Trends Study was performed. Race was based on self-report. Primary outcome was activity limitations (requiring assistance with mobility, self-care, and household activities). Secondary outcome was participation restrictions, which were defined as reductions/absence in valued social activities because of health. Physical capacity was measured by a validated scale (0 low–12 high). Logistic regression was used to estimate average marginal effects of activity limitations and participation restrictions by race before and after adjusting for sociodemographics, comorbidities, and physical and cognitive capacity. Results: Non-Hispanic black participants had lower physical capacity than non-Hispanic white participants (mean 5.1 vs 6.9, p < 0.01). For most activities, black participants had significantly greater limitations than white participants. These differences persisted after accounting for sociodemographic factors and comorbidities, but largely became nonsignificant after accounting for physical capacity. The only unadjusted racial difference in participation restriction was in religious service attendance (18.2% of white participants vs 28.6% of black participants, p < 0.01). Conclusion: After stroke, black individuals have a greater prevalence of activity limitations than white individuals, largely due to their greater physical capacity limitations. Further understanding of the causes of racial differences in capacity after stroke is needed to reduce activity limitations after stroke and decrease racial disparities.

Effect of insurance status on postacute care among working age stroke survivors

Objective: Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors. Methods: A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004–2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities. Results: Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47–0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27–1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36–0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23–0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors. Conclusions: Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.

Fatalism, Optimism, Spirituality, Depressive Symptoms, and Stroke Outcome A Population-Based Analysis

Background and Purpose— We sought to describe the association of spirituality, optimism, fatalism, and depressive symptoms with initial stroke severity, stroke recurrence, and poststroke mortality. Methods— Stroke cases from June 2004 to December 2008 were ascertained in Nueces County, TX. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and nonorganizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed National Institutes of Health Stroke Scale and Cox proportional hazards regression for recurrence and mortality. Results— Six hundred sixty-nine patients participated; 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (hazard ratio, 1.41; 95% CI, 1.06–1.88) and marginally associated with risk of recurrence (hazard ratio, 1.35; 95% CI, 0.97–1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (hazard ratio, 1.32; 95% CI, 1.02–1.72), marginally associated with stroke recurrence (HR, 1.22; 95% CI, 0.93–1.62), and with a 9.0% increase in stroke severity (95% CI, 0.01–18.0). Depressive symptoms altered the fatalism–mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence, or mortality. Conclusions— Among patients who have already had a stroke, self-described prestroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations and may be novel targets for intervention.

Choosing Wisely: Highest-cost tests in outpatient neurology

Identifying the tests/procedures ordered by neurologists that contribute most to health care expenditures is a critical step in the process of creating the neurology top 5 list for the Choosing Wisely initiative. Using data from the 2007–2010 National Ambulatory Care Medical Survey, we found that

Factors Influencing Sex Differences in Poststroke Functional Outcome

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