Disparities in Stroke Rehabiliation: Results of a Study in an Integrated Health System in Northern California

Physical Medicine and Rehabilitation, Napa Solano Service Area, and Research and Training, Kaiser Foundation Rehabilitation Center, Vallejo, CA 94589, USA.
PM&R (Impact Factor: 1.53). 02/2009; 1(1):29-40. DOI: 10.1016/j.pmrj.2008.10.012
Source: PubMed


To determine whether there are disparities in postacute stroke rehabilitation based on type of stroke, race/ethnicity, sex/gender, age, socioeconomic status, geographic region, or service area referral patterns in a large integrated health system with multiple levels of care.
Cohort study tracking rehabilitation services for 365 days after acute hospitalization for a first stroke.
The Northern California Kaiser Permanente Health System (approximately 3.3 million membership population)
A total of 11,119 patients hospitalized for acute stroke from 1996 to 2003. The cohort includes patients discharged from acute care after a stroke. Postacute care rehabilitation services were evaluated according to the level of care ever-received within the 365 days after discharge from acute care, including inpatient rehabilitation hospital (IRH), skilled nursing facility (SNF), home health and outpatient, or no rehabilitation services.
Not applicable.
Service delivery.
Patients discharged to an IRH had longer lengths of stay in acute care. Patients with hemorrhagic stroke were less likely to be treated in an IRH. Patients whose highest level of rehabilitation was SNF were older and more likely to be women. After adjusting for age and other covariates, women were less likely to go to an IRH than men. Asian and black patients were more likely than white patients to be treated in an IRH or SNF. Also more likely to go to an IRH were patients from higher socioeconomic groups, from urban areas, and from geographic areas close to the regional rehabilitation hospital.
These results suggest variation in care delivery and extent of postacute care based on differences in patient demographics and geographic factors. Results also varied over time. Some minority populations in this cohort appeared to be more likely to receive IRH care, possibly because of disease severity, family support systems, cultural factors, or differences in referral patterns.

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    • "Freburger et al. [30] found that post-acute care varied significantly between four states in the USA even after controlling for patient and hospital characteristics. A study performed within the Northern California Kaiser Permanente Health System found that patients in one administrative area were twice more likely to get inpatient rehabilitation than patients in other areas [32]. "
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    ABSTRACT: Medical events, such as stroke, limb fractures, joint replacements and spinal injuries, can lead to acute functional disability at all ages and to chronic disability, especially among the elderly. Rehabilitation is, therefore, essential for the prevention of permanent disability among older individuals. There are international practice guidelines for stroke and hip fracture management, including recommendations that rehabilitation services be an integral part of the provision of treatment in either an inpatient setting or in the community. There are no organized data on provision of rehabilitation services in Israel or on the distribution of these services throughout the country. Such information would be of great assistance in designing these services where they are needed and in making changes in the existing ones where necessary. Patients aged 65 years or older with stroke or hip fracture were identified through one-day surveys conducted in 2009--2010 in all 26 acute care hospitals in Israel. Data on inpatient and ambulatory rehabilitation services were collected from discharge medical summaries, telephone interviews with the patients or their relatives and reports from the healthcare provider. The extent of rehabilitation services was described and the association between receipt of inpatient rehabilitation and the geographic district based on the patients' listed address was examined in a multivariate analysis. A total of 570 patients with stroke and 768 patients with hip fracture were identified and interviews were conducted in regards to 421 and 672 respectively. Out of the stroke patients 238(56.5%) received inpatient rehabilitation, 46(10.9%) received ambulatory rehabilitation treatment without inpatient phase and 137 (32.5%) received no rehabilitation. In fracture these rates were 494(73.5%), 96(14.3%) and 82(12.2%) respectively. Patients living in districts with lower availability of rehabilitation beds were less likely to receive inpatient rehabilitation after controlling for patient characteristics. Regional disparities in the provision of inpatient rehabilitation care for elderly after an acute episode of stroke or hip fracture were identified and could be partially attributed to the distribution of rehabilitation beds. These findings highlight the need to plan the rehabilitation resources based on the population needs and to routinely monitor the provision of these services.
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    • "Concernant la réadaptation , différentes études soulignent l'hétérogénéité des ressources et des pratiques [21] [22] [23] [24] [25]. De fait, les ressources disponibles et leur proximité ont un impact sur l'orientation [21] [26]. C'est pour cela qu'une étude globale du modèle français de prise en charge des patients au décours d'un accident vasculaire cérébral, et de ses évolutions était impor- tante. "
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    • "In general, there is greater evidence for Hispanics using less intensive PARC than Non-Hispanic Whites (Ottenbacher et al., 2003)(Ganesan, Pan, Teklehaimenot, & Norris, 2005)than for differences between African-Americans and Whites (Kind et al., 2010; Schwamm et al., 2010)Some studies have found more intensive use by racial and ethnic minorities (M. B. Buntin, 2007)with the strongest disparity being with African-Americans receiving more intensive care (Harada, Chun, Chiu, & Pakalniskis, 2000)(Sandel et al., 2009) (Onukwugha & Mullins, May/June 2007)(Feng, Nietert, & Adams, 2009; Sandel et al., 2009; Schwamm et al., 2010)Other studies have found no racial or ethnic disparities in use of PARC. (Bhandari, Kushel, Price, & Schillinger, 2005)(Horner, Swanson, Bosworth, Matchar, & VA Acute Stroke (VAST) Study Team, 2003)(Gregory, Han, Morozova, & Kuhlemeier, 2006) The differences in conditions receiving PARC, the wide variety of covariates and outcomes examined, and differences in study designs, analytical methods, and populations has led to a very mixed picture of racial disparities in the use of PARC. "
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