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


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

In This Article


Overall, approximately one third of stroke survivors reported participating in stroke outpatient rehab. Although outpatient rehab use increased significantly in the four states that collected data in both 2013 and 2015, it remained suboptimal,[3] highlighting missed opportunities to reach stroke survivors. Stroke recovery can be a long and complex process, involving multiple domains of therapy (e.g., physical, occupational, communication, and cognitive) and occurs in inpatient rehabilitation facilities, skilled nursing facilities, and outpatient rehabilitation facilities. Benefits of stroke outpatient rehab have been determined to improve patient functional status, survival, cardiovascular risk profiles, and quality of life and reduce risks for recurrent strokes and psychological or stress disorders.[3,4,8,9] Generally, stroke outpatient rehab participation is underutilized,[3,8] which this study found to be true for all subgroups and states included in the analysis. No subgroup had outpatient rehab use rates >40%, and no state had use rates >50%. Although the overall prevalence of outpatient rehab use was low, disparities in use were evident. Younger adults, women, non-Hispanic persons of other than black or white races, Hispanics, and adults with less than a high school education were less likely to use stroke outpatient rehab than their counterparts. Disparities in stroke outpatient rehab at the state level were also apparent. For example, adjusted outpatient rehab use prevalence in Minnesota (43.6%) was almost twice that in Oregon (23.1%).

Increasing participation in stroke outpatient rehab has been recognized as a national priority. Healthy People 2020** aims to increase the proportion of adult stroke survivors who are appropriately and effectively assessed and referred for rehabilitation services. The estimates from the Healthy People 2020 objective are high (90% during 2008–2011); however, they are reflective of assessment or referral, not participation.[4] Improving coordination of care to support assessment, referral, and, ultimately, participation in rehab is needed. The continued underutilization of outpatient stroke rehab might be related to lack of patient access to outpatient facilities, ineffective referral from health care providers, high out-of-pocket costs, lack of health insurance coverage, or lack of knowledge and awareness of benefits of outpatient rehab for stroke survivors.[4,6] The CDC-supported Paul Coverdell National Acute Stroke Program†† seeks to better understand the care provided to stroke survivors to identify disparities and support quality improvement around the assessment for, effective referral to, and provision of stroke rehab services. Experiences from such programs can support system-level changes that encourage use of stroke rehab services across all subgroups and geographies.

The findings in this report are subject to at least five limitations. First, BRFSS data are self-reported and subject to recall bias. Moreover, recall bias might lead to participants inaccurately reporting the type of stroke rehab they used (i.e., outpatient rehab versus inpatient rehabilitation facilities, skilled nursing facilities, and home health rehab).[10] Second, the survey does not capture stroke severity, variations in rehabilitation needs, or information about why participants did not participate in outpatient rehab. Third, the optional module was only used by selected states, and the findings should not be considered as nationally representative. Fourth, with few respondents reporting a history of stroke (162 in the District of Columbia to 1,618 in Florida), some state-level confidence intervals were wide, and results should be interpreted with caution. Finally, only participation in outpatient rehab was included in the module, limiting the ability to assess participation in other rehab modalities.

Although estimates of stroke outpatient rehab referral might be high, participation in stroke outpatient rehab remains suboptimal. Barriers to participation in stroke outpatient rehab are evident,[3,8–10] but focused attention on system-level interventions that ensure participation is needed, especially among populations with lower levels of participation. Interventions that might improve outpatient rehab participation include increasing coverage for outpatient rehab services by health insurers, reducing copayments, extending rehab clinic hours to improve access availability, and implementing standardized assessments by health care professionals to guide appropriate referrals to outpatient rehab at hospital discharge.[3–5,8] Stroke survivors should be educated about stroke outpatient rehab opportunities possibly available in their community that reduce barriers related to transportation and time (e.g., telehealth, mobileHealth, and home-based care).[3,5,6,8–10]

**Healthy People 2020 Heart Disease and Stroke Objectives (HDS-23).
††The Coverdell program works with health systems across funded recipient states to gather data and drive quality improvement in the prehospital, in-hospital, and posthospital care settings.