Use of Outpatient Rehabilitation Among Adult Stroke Survivors — 20 States and the District of Columbia, 2013, and Four States, 2015

Carma Ayala, PhD; Jing Fang, MD; Cecily Luncheon, MD, DrPH; Sallyann Coleman King, MD; Tiffany Chang, MPH; Matthew Ritchey, DPT; Fleetwood Loustalot, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(20):575-578.

Abstract and Introduction

Introduction

Stroke is a leading cause of mortality and disability in the United States.^[1,2] Approximately 800,000 American adults experience a stroke each year.^[2,3] Currently, approximately 6 million stroke survivors live in the United States.^[2] Participation in stroke rehabilitation (rehab), which occurs in diverse settings (i.e., in-hospital, postacute care, and outpatient settings), has been determined to reduce stroke recurrence and improve functional outcomes and quality of life.^[3,4] Despite longstanding national guidelines recommending stroke rehab, it remains underutilized, especially in the outpatient setting. Professional associations and evidence-based guidelines support the increasing stroke rehab use in health systems and are promoted by the public health community.^[3–6] An analysis of 2005 Behavioral Risk Factor Surveillance System (BRFSS) data revealed that 30.7% of stroke survivors reported participation in outpatient rehab for stroke after hospital discharge in 21 states and the District of Columbia (DC).^[7] To update these estimates, 2013 and 2015 BRFSS data were analyzed to assess outpatient rehab use among adult stroke survivors. Overall, outpatient rehab use was 31.2% (20 states and DC) in 2013 and 35.5% (four states) in 2015. Disparities were evident by sex, race, Hispanic origin, and level of education. Focused attention on system-level interventions that ensure participation is needed, especially among disparate populations with lower levels of participation.

BRFSS is a telephone survey of the noninstitutionalized U.S. population* conducted annually by all states. The cardiovascular health module, which includes questions about rehab participation, was an optional module in 2013 and 2015. In 2013, the median cardiovascular health module response rate^† for 20 states^§ was 46.2%. Among the four states^¶ participating in the module in both 2013 and 2015, the response rate was 49.3% in 2013 and 51.5% in 2015.

Stroke survivors were identified by the question "Has a doctor, nurse, or other health professional ever told you that you had a stroke?" Participation in outpatient stroke rehab was only asked of those with a history of stroke and was identified among respondents who answered "yes" to the question "Following your stroke, did you go to any kind of outpatient rehabilitation?" Demographic characteristics collected included age, sex, race, Hispanic origin, education (less than high school, high school graduate, some college, or college graduate) and health insurance status. Selected cardiovascular disease risk factors included hypertension, high blood cholesterol, diabetes, obesity, and current smoking. Percentages of respondents who participated in stroke rehab were measured, overall, by demographic characteristics, by cardiovascular disease risk factors in 2013, and by state of residence, and were adjusted for age, sex, race/Hispanic origin, education, insurance status, presence of cardiovascular disease risk factors, and number of cardiovascular disease risk factors (0, 1, 2, 3, 4, or 5). Adjusted percentages and 95% confidence intervals (CIs) were calculated; p-values <0.05 (obtained using Wald F test) were regarded as statistically significant. Statistical software was used to account for the complex sampling design.

In 2013, among 168,655 BRFSS participants, 3.3% (95% CI = 3.1%–3.4%) reported a history of stroke and were classified as stroke survivors. In 2015, among 21,047 participants, 3.3% (95% CI = 3.0%–3.8%) were stroke survivors. In 2013, stroke outpatient rehab participation was 31.2% (95% CI = 29.1%–33.4%) (Table 1). Men, non-Hispanic blacks, and those with a college education or higher more frequently reported participating in stroke outpatient rehab than did women, non-Hispanic others, Hispanics, and those with less than a high school education.

Total adjusted outpatient rehab participation was 31.2% in 2013 and 35.5% in 2015 (Table 2). In 2013, adjusted percentages ranged from 23.1% in Oregon to 43.6% in Minnesota. The unadjusted and adjusted percentages of stroke survivors who took part in outpatient rehab in 2015 were lowest in Maine (28.0% and 31.3%, respectively) and highest in Iowa (46.1% and 49.8%, respectively). Among the four states that included stroke outpatient rehab questions in both 2013 and 2015, the overall adjusted percentage of stroke outpatient rehab participation increased 8.3 percentage points, from 27.2% in 2013 to 35.5% in 2015 (p<0.05).

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Abstract and Introduction
Discussion
References
Sidebar

*https://www.cdc.gov/brfss.
^†The overall median response rates were 46.4% in 2013 and 47.2% in 2015 for all 50 states and territories with participants in the BRFSS.
^§Arizona, Arkansas, District of Columbia, Florida, Georgia, Hawaii, Iowa, Maine, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, Tennessee, Washington, and Wisconsin.
^¶Georgia, Iowa, Maine, and Oregon.

Table 1. Unadjusted and adjusted* percentages of adults who survived a stroke and received outpatient stroke rehabilitation, by demographic characteristics and presence of cardiovascular disease risk factors — Behavioral Risk Factor Surveillance System (BRFSS), 20 U.S. states and the District of Columbia, 2013
Characteristic	Sample size	Unadjusted % (95% CI)	P-value^†	Adjusted* % (95% CI)	P-value
Total	6,743	31.2 (29.1–33.4)	—	31.2 (29.1–33.4)	<0.001
Sex
Men	2,616	33.7 (30.4–37.2)	0.038	33.8 (30.5–37.2)	0.030
Women	4,127	29.1 (26.5–31.9)	0.038	29.1 (26.4–31.8)	0.030
Age group (yrs)
18–64	2,468	30.9 (27.6–34.4)	0.798	30.6 (27.5–34.0)	0.622
≥65	4,275	31.5 (29.0–34.1)	0.798	31.7 (29.0–34.6)	0.622
Race/Ethnicity
White, non-Hispanic	5,132	30.3 (28.0–32.7)	0.019	30.0 (27.6–32.5)	0.013
Black, non-Hispanic	966	39.1 (32.9–45.7)		39.8 (33.6–46.2)
Hispanic	481	26.5 (20.0–34.1)		26.7 (20.3–34.3)
Other, non-Hispanic	164	24.4 (15.9–35.6)	—^§	25.8 (17.0–37.0)	—^§
Education
Less than high school	1,141	25.8 (21.5–30.6)	0.025	25.7 (21.4–30.5)	0.022
High school	2,255	32.5 (28.9–36.2)		32.3 (28.8–36.2)
Some college	1,923	31.9 (28.0–36.1)		32.1 (28.3–36.2)
College or higher	1,424	36.3 (31.5–41.2)		36.4 (31.5–41.5)
Insurance
Yes	6,276	31.6 (29.5–33.7)	0.492	31.3 (29.2–33.5)	0.836
No	467	28.2 (20.2–38.0)	0.492	30.3 (21.9–40.2)	0.836
CVD risk factors (no.)^¶
0	455	35.6 (27.0–45.3)	0.382	35.6 (27.4–40.2)	0.478
1	1,349	29.2 (24.7–34.2)		29.4 (24.9–44.7)
2	2,103	30.1 (26.5–33.9)		30.3 (26.7–34.4)
3	1,805	31.5 (28.0–35.2)		31.2 (27.7–34.9)
4	918	34.8 (28.7–41.5)		34.5 (28.5–41.1)
5	113	21.8 (12.6–35.1)	—^§	22.9 (13.3–36.5)	—^§

Abbreviations: CI = confidence interval; CVD = cardiovascular disease.
*Adjusted for age, sex, race/ethnicity, education, insurance status, and CVD risk.
^†P-values were obtained using Wald F test to identify statistically significant differences among subgroup.
^§BRFSS recommends that data be suppressed when relative standard error (RSE) is >30% or denominator <50; it is also suggested that if RSE is 20%–30%, the estimates are potentially unreliable.
^¶Selected self-reported CVD risk factors include hypertension, high blood cholesterol, diabetes, obesity, and current smoking. Categories were assigned based on the number of risk factors present: 0, 1, 2, 3, 4, or 5.

Table 2. Crude and adjusted percentages* of adults who survived a stroke and received stroke outpatient rehabilitation, by state and ascending adjusted percentage — Behavioral Risk Factor Surveillance System, 20 U.S. states and the District of Columbia (DC), 2013, and four U.S. states, 2015
Year/State^†	No.	Unadjusted % (95% CI)	P–value^§	Adjusted* % (95% CI)	P–value^§
2013
Total (20 states and DC)	6,743	31.2 (29.1–33.4)	0.003	31.2 (29.1–33.4)	0.012
Oregon	202	22.7 (16.8–29.9)		23.1 (17.1–30.5)
Georgia	306	24.8 (19.3–31.2)		23.7 (18.5–29.9)
Oklahoma	197	23.8 (17.0–32.3)		24.6 (17.3–33.5)
Hawaii	210	24.1 (17.4–32.3)		25.9 (17.8–36.0)
North Dakota	230	26.0 (19.5–33.8)		27.0 (20.3–34.9)
Maine	139	27.2 (19.4–36.6)		28.1 (20.2–37.6)
Tennessee	254	27.7 (20.8–35.9)		28.1 (21.0–36.5)
Arkansas	278	27.9 (20.9–36.2)		29.1 (22.3–37.0)
Florida	1,618	30.6 (25.8–35.8)		30.0 (25.4–35.0)
Washington	378	30.6 (24.5–37.5)		30.8 (24.5–37.9)
Arizona	170	30.7 (20.9–42.6)		32.1 (22.2–43.9)
Wisconsin	166	31.1 (21.2–42.9)		32.4 (22.3–44.4)
District of Columbia	162	39.0 (28.5–50.8)		32.7 (22.5–44.8)
Missouri	319	31.8 (24.8–39.7)		32.8 (25.8–40.7)
North Carolina	204	32.9 (24.5–42.6)		33.4 (24.8–43.2)
Mississippi	426	35.5 (28.4–43.2)		34.0 (26.8–42.0)
South Carolina	441	37.4 (31.1–44.1)		35.8 (29.6–42.5)
Massachusetts	112	38.9 (24.1–56.0)	—^¶	37.8 (24.8–52.9)	—^¶
Nebraska	291	38.9 (30.6–47.8)		39.6 (30.7–49.3)
Iowa	263	40.6 (33.4–48.1)		41.7 (34.5–49.4)
Minnesota	377	43.0 (31.5–55.2)		43.6 (31.0–57.1)
2013
Total (four states)	910	27.2 (23.5–31.3)	0.001	27.4 (23.5–31.3)	0.0004
Oregon	202	22.7 (16.8–29.9)		22.7 (16.2–30.8)
Georgia	306	24.8 (19.3–31.2)		24.2 (18.8–30.6)
Maine	139	27.2 (19.4–36.6)		28.4 (20.3–38.2)
Iowa	263	40.6 (33.4–48.1)		41.7 (34.4–49.4)
2015
Total (four states)	729	35.5 (29.6–41.8)	0.033	35.5 (29.6–41.8)	0.008
Maine	182	28.0 (21.0–36.3)		31.3 (23.1–41.0)
Georgia	201	34.0 (25.4–43.8)		31.8 (24.2–40.6)
Oregon	180	36.2 (26.8–46.7)		39.7 (29.6–50.8)
Iowa	166	46.1 (37.2–55.3)		49.8 (40.3–59.3)

Abbreviation: CI = confidence interval.
*Adjusted for age, sex, race/ethnicity, education, insurance status and cardiovascular disease risk factors.
^†States are listed in ascending order of adjusted percentages for outpatient stroke rehabilitation in 2013 and 2015.
^§P-values were obtained using Wald F test to identify statistically significant differences among states within each year; comparison of differences between 2013 and 2015 among four states only was p = 0.0289.