W. Bruce Vogel

Ethnic Disparities in Stroke Epidemiology, Acute Care, and Postacute Outcomes

Background and Purpose— Evidence for ethnic disparities in stroke incidence, severity, and mortality has continued to mount in recent years. However, the picture for disparities in acute management and rehabilitation remains more ambiguous. The objective of this report is to summarize current evidence from stroke epidemiology and studies focusing on disparities in stroke care and disability, suggesting courses for action. Methods— A comprehensive search of current literature on ethnic/racial variation in stroke incidence, mortality, and severity, as well as acute and postacute patient care was performed. Results— Recent evidence unambiguously reaffirms a greater burden of disease in stroke, greater mortality, and greater severity of strokes for blacks. Evidence for disparities in acute and postacute care is less conclusive, as is the evidence for disparities among other ethnic groups. Evidence for health disparities in stroke care across settings, regions, and the continuum of care varies considerably. Conclusions— Minority ethnic groups have higher rates or more severe stroke, but variations in prognosis for clinical outcomes other than mortality remain less certain. There is considerable need for more studies that take into account regional ethnic variations in treatment and outcomes, and for better documentation of stroke outcomes among groups in addition to blacks. Dealing with ethnic disparities in stroke will be served by sustained attention to quality improvement in high-impact areas in stroke care, complemented by initiatives that promote cultural competence.

Addressing ceiling effects in health status measures: a comparison of techniques applied to measures for people with HIV disease.

OBJECTIVES To compare different approaches to address ceiling effects when predicting EQ-5D index scores from the 10 subscales of the MOS-HIV Health Survey. STUDY DESIGN Data were collected from an HIV treatment trial. Statistical methods included ordinary least squares (OLS) regression, the censored least absolute deviations (CLAD) approach, a standard two-part model (TPM), a TPM with a log-transformed EQ-5D index, and a latent class model (LCM). Predictive accuracy was evaluated using percentage of absolute error (R(1)) and squared error (R(2)) predicted by statistical methods. FINDINGS A TPM with a log-transformed EQ-5D index performed best on R(1); a LCM performed best on R(2). In contrast, the CLAD was worst. Performance of the OLS and a standard TPM were intermediate. Values for R(1) ranged from 0.33 (CLAD) to 0.42 (TPM-L); R(2) ranged from 0.37 (CLAD) to 0.53 (LCM). CONCLUSIONS The LCM and TPM with a log-transformed dependent variable are superior to other approaches in handling data with ceiling effects.

Multiple System Utilization and Mortality for Veterans With Stroke

Background and Purpose— Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. Methods— Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. Results— The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). Conclusions— Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

The Effectiveness of Inpatient Rehabilitation in the Acute Postoperative Phase of Care After Transtibial or Transfemoral Amputation: Study of an Integrated Health Care Delivery System

OBJECTIVE To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Impact of Comorbidities on Stroke Rehabilitation Outcomes: Does the Method Matter?

OBJECTIVES To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures--the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)--in how well they predict these outcomes. DESIGN Inception cohort of patients followed for 6 months. SETTING Department of Veterans Affairs (VA) hospitals. PARTICIPANTS A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score. RESULTS During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R(2) values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R(2) of .111 for change in FIM score. CONCLUSIONS Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.

Factors influencing high and low profitability among hospitals

This article examines the determinants of exceptionally high and exceptionally low profitability among hospitals. Using 1989 data from a sample of 169 acute care hospitals in Florida, it reveals that debt load, labor intensity, and Medicare mix play important roles in exceptional profitability. Administrators can therefore take selected actions over the long run to alter their hospitals chance of exhibiting exceptionally high or exceptionally low profitability.

Improving Hip Fractures Outcomes for COPD Patients

Abstract Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veterans Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients. Methods: Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005. Results: COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was “severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV1 <75% predicted), and in 2,736 (21%) cases it was considered “mild” (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects. Conclusions: COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.

Survival Analysis in Amputees Based on Physical Independence Grade Achievement

BACKGROUND Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE Cumulative 6-month survival after rehabilitation discharge. RESULTS The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

The effect of premium changes on SCHIP enrollment duration.

RESEARCH OBJECTIVE To examine the impact of premium changes in Floridas State Childrens Health Insurance Program (SCHIP) on enrollment duration. DATA SOURCES Administrative records, containing enrollment and demographic data, were used to identify 173,330 enrollment spells for 153,768 children in Floridas SCHIP from July 2002 through June 2004. Health care claims data were used to classify the childrens health status. STUDY DESIGN Accelerated failure time models were used to examine the immediate and longer term effects on enrollment length of a temporary premium increase of

Community-based nursing: Continence care for older rural women☆

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