Functional Outcomes After Stroke May Be Worse in Women, Minorities

LOS ANGELES — After controlling for stroke severity, women, minorities, and those with a previous stroke, women and minorities had worse functional status at 3 months following stroke, data presented here indicate.

“Women and non-white minorities had lower Stroke Impact Scale-16 (SIS-16) scores, whereas [patients with] diabetes, depression, prior stroke/[transient ischemic attack (TIA)], and age did not, even after adjusting for stroke severity,” Cheryl Bushnell, MD, MHS, of the Wake Forest School of Medicine in Winston Salem, N.C., said in an interview with Neurology Advisor.

Dr Bushnell and colleagues conducted the study, which was presented at the 2016 International Stroke Conference.

According to study background, functional outcomes after stroke are important to patients, but are not found in administrative data, leading researchers to use a hospital quality improvement program to determine outcomes 3 months after discharge. They evaluated the association between outcomes measured with the SIS-16 and sex, comorbidities, depression, and risk factors.

“The catalyst for the study was to see if comorbidities and the management of them might influence functional status,” Dr Bushnell said. “But, we pre-specified gender and race because we knew these could be important predictors of outcome.”

The study included patients who had ischemic/hemorrhagic stroke or transient ischemic attack (TIA) and were in an ongoing hospital-supported quality improvement program that concentrated on transitional care and outcomes. Dr Bushnell and colleagues used the SIS-16 to determine self-reported mobility, arm strength, and basic/instrumental activities of daily living.

The range of transformed scores was 0 (worst) to 100 (best), and questionnaires were mailed to patients 3 months after discharge or collected by phone if there was no mailed response.

In all, 90-day outcomes were obtained from 129 patients (mean age, 66 years; 45.7% women; 73% white) between September 2011 and April 2015. The mean National Institutes of Health Stroke Scale (NIHSS) score was 4, and 28% of patients had diabetes, 82% had hypertension, 15.6% had coronary artery disease, 35% had prior stroke/TIA, and 7% had pre-stroke depression.

Overall, 37% of patients received no therapy, 14.7% received inpatient therapy, 24% received home health therapy, and 23.2% received outpatient therapy.

The SIS-16 score was 81.1. Predictors of a lower SIS-16 score included female gender (P=.007), non-white race (P<.001), and NIHSS score (P<.0001).

Furthermore, in a stepwise linear regression model that adjusted for NIHSS, female gender (P=.007) and non-white race (P=.002) yielded poorer functional status, while a trend was found in patients with prior stroke/TIA (P=.095).

“Women and minorities have poorer functional outcome after stroke, but the reasons for this outcome need to be further explored,” Dr Bushnell said. “Our model showed that we only explained 31% of the variance in SIS-16 with gender, race/ethnicity, and stroke severity, so unmeasured factors are extremely important. We could speculate from this dataset and other published data that women may be more likely to have functional deficits prior to stroke, be unmarried/widowed, live alone, or be institutionalized after stroke. Non-white stroke survivors may have poorer access to care, have multiple strokes, and more comorbidities.”  

Dr Bushnell added that she and colleagues will continue to collect functional outcomes and have a process for doing so among all stroke survivors discharged home. 

“As we move toward value-based care, these outcomes will become the focal point for our post-acute care processes,” she said. “Knowing which patients might have worse functional outcomes is an important step.”

For more coverage of ISC 2016, go here.

Reference

Bushnell C, Prvu-Bettger J, D’Agostino R, et al. Abstract 108. Women and Minorities have Lower Patient-reported Functional Status 3 Months Post-stroke. Presented at: International Stroke Conference; Feb. 16-19, 2016; Los Angeles.