Skolarus Lesli E, Feng Chunyang, Burke James F
From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.).
Department of Neurology, Ann Arbor VA, MI (J.F.B.).
Stroke. 2020 Jun;51(6):1813-1819. doi: 10.1161/STROKEAHA.119.027700. Epub 2020 May 14.
Background and Purpose- Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods- A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009-2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0-7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results- There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7-2.2]; =0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2-2.4]; =0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0-3.2] in blacks versus 1.4 [1.0-1.8] in whites, mean difference, 1.2 [0.5-1.9], <0.001) and immediately poststroke (2.6 [2.0-3.3] in blacks versus 1.7 [1.2-2.1] in whites, mean difference, 1.0 [0.2-1.7], <0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions- Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.
背景与目的——横断面分析发现中风后残疾存在巨大的种族差异，但这些分析未考虑中风前的残疾情况、住院因素、急性后期护理、转诊或死亡率。在此背景下，我们对中风后至少存活90天的老年中风幸存者进行纵向分析，以探讨死亡率、养老院安置情况和残疾情况。方法——使用来自与医疗保险相关的国家健康与老龄化趋势研究（2009 - 2016年）的黑人和白人中风幸存者前瞻性队列。在面对面访谈期间使用经过验证的量表（0 - 7）评估残疾情况。我们使用Cox比例风险模型分别评估死亡率和养老院入住情况，并对年龄、性别、社会人口统计学特征（婚姻状况、教育程度、收入、保险状况、社交网络规模）、合并症、住院因素、急性后期护理和90天再入院情况进行调整。为了估计残疾方面的种族差异，我们使用多水平线性回归模型，最初对年龄和性别进行调整，然后与对社会人口统计学特征、合并症、住院因素、急性后期护理和90天再入院情况进行调整的模型进行比较。结果——共有282名中风幸存者，其中76名（12.6%）为黑人。在长期死亡率（黑人的风险比为1.2 [95% CI，0.7 - 2.2]；P = 0.5）或养老院安置情况（黑人的风险比为0.7 [95% CI，0.2 - 2.4]；P = 0.5）方面不存在种族差异。在残疾方面观察到的最大种族差异出现在中风前即刻，经年龄和性别调整后的估计活动受限情况为（黑人2.6 [2.0 - 3.2]，白人1.4 [1.0 - 1.8]，平均差异1.2 [0.5 - 1.9]，P < 0.001）以及中风后即刻（黑人2.6 [2.0 - 3.3]，白人1.7 [1.2 - 2.1]，平均差异1.0 [0.2 - 1.7]，P < 0.01）。完全调整后，种族与残疾之间的关联没有实质性变化。结论——在养老院安置、长期死亡率、社会人口统计学特征、合并症、住院因素、急性后期护理和再入院方面的种族差异不太可能是中风后残疾种族差异的主要促成因素。需要进一步研究以了解中风后残疾种族差异的驱动因素。
